Rep. Mark Green, MD, of Tennessee has reintroduced legislation taking aim at prior authorization requirements in Medicare, Medicare Advantage and Part D prescription drug plans.
Five things to know:
1. The proposed legislation would reform the prior authorization process in Medicare and Medicare Advantage by requiring that board-certified physicians in the same specialty be responsible for determining the medical need of prior authorization requests, according to a March 28 news release from Dr. Green’s office.
2. The bill also directs Medicare, Medicare Advantage and Part D plans to comply with requirements that prior authorization restrictions be based on medical necessity, written clinical criteria and additional transparency obligations.
3. If no evidence-based standards exist for a healthcare service, insurers cannot deny coverage solely on that basis, according to the legislation.
4. The bill has been endorsed by several medical organizations, including the American Medical Association, the Medical Group Management Association, and the American Osteopathic Association.
5. “Often, prior authorization requests are reviewed — and denied — by insurance company representatives who lack the medical expertise to appropriately judge what level of care is necessary for a patient,” AMA President Bruce Scott, MD, said. “This welcome legislation would require the reviewers to be physicians with actual experience in the field of medicine they are passing judgment over.”
