/ en Thu, 22 May 2025 21:20:48 -0500 Wed, 21 May 25 14:01:38 -0500 /lettercomment/2025-05-21-aha-senate-letter-supporting-improving-seniors-timely-access-care-act <div class="container"><div class="row"><div class="col-md-8"><p>May 21, 2025</p><div class="row"><div class="col-md-6"><p>The Honorable Roger Marshall, M.D.<br>United States Senate<br>479A Russell Senate Office Building<br>Washington, DC 20510</p></div><div class="col-md-6"><p>The Honorable Mark Warner<br>United States Senate<br>703 Hart Senate Office Building<br>Washington, DC 20510</p></div></div><p>Dear Senators Marshall and Warner:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners 鈥� including more than 270,000 affiliated physicians, 2 million nurses and other caregivers 鈥� and the 43,000 health care leaders who belong to our professional membership groups, the 黑料正能量 Association (AHA) is pleased to support your legislation, the Improving Seniors鈥� Timely Access to Care Act.</p><p>Inefficient prior authorization requirements are a pervasive problem among certain plans in the Medicare Advantage (MA) program that result in delays in care and add financial burden and strain to the health care system. Your bipartisan legislation would address these issues through streamlining prior authorization requirements under MA plans by eliminating complexity and promoting uniformity that would reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p>Specifically, your bill would establish an electronic prior authorization standard to streamline approvals, reduce the time a health plan is allowed to consider a prior authorization request, require MA plans to report on their use of prior authorization, including the use of artificial intelligence in prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.</p><p>Thank you for your support in improving the prior authorization process to increase patient access to care and reduce the burden for providers. We look forward to continuing to work with you on this issue and urge Congress to pass this bill to ensure all Medicare beneficiaries have access to timely and appropriate care.</p><p>Sincerely,<br>/s/<br>Stacey Hughes<br>Executive Vice President</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/aha-senate-letter-supporting-improving-seniors-timely-access-to-care-act-5-21-2025.pdf" target="_blank" title="Click here to download the AHA Senate Letter Supporting Improving Seniors鈥� Timely Access to Care Act PDF.">Download the Letter PDF</a></div></div></div></div> Wed, 21 May 2025 14:01:38 -0500 Prior Authorization /lettercomment/2025-05-21-aha-house-letter-supporting-improving-seniors-timely-access-care-act <div class="container"><div class="row"><div class="col-md-8"><p>May 21, 2025</p><div class="row"><div class="col-md-6"><p>The Honorable Mike Kelly<br>U.S. House of Representatives<br>1707 Longworth House Office Building<br>Washington, DC 20515</p></div><div class="col-md-6"><p>The Honorable Ami Bera, M.D.<br>U.S. House of Representatives<br>172 Cannon House Office Building<br>Washington, DC 20515</p></div></div><div class="row"><div class="col-md-6"><p>The Honorable Suzan DelBene<br>U.S. House of Representatives<br>2311 Rayburn House Office Building<br>Washington, DC 20515</p></div><div class="col-md-6"><p>The Honorable John Joyce, M.D.<br>U.S. House of Representatives<br>2102 Rayburn House Office Building<br>Washington, DC 20515</p></div></div><p>Dear Representatives Kelly, DelBene, Bera and Joyce:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners 鈥� including more than 270,000 affiliated physicians, 2 million nurses and other caregivers 鈥� and the 43,000 health care leaders who belong to our professional membership groups, the 黑料正能量 Association (AHA) is pleased to support your legislation, the Improving Seniors鈥� Timely Access to Care Act.</p><p>Inefficient prior authorization requirements are a pervasive problem among certain plans in the Medicare Advantage (MA) program that result in delays in care and add financial burden and strain to the health care system. Your bipartisan legislation would address these issues through streamlining prior authorization requirements under MA plans by eliminating complexity and promoting uniformity that would reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p>Specifically, your bill would establish an electronic prior authorization standard to streamline approvals, reduce the time a health plan is allowed to consider a prior authorization request, require MA plans to report on their use of prior authorization, including the use of artificial intelligence in prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.</p><p>Thank you for your support in improving the prior authorization process to increase patient access to care and reduce the burden for providers. We look forward to continuing to work with you on this issue and urge Congress to pass this bill to ensure all Medicare beneficiaries have access to timely and appropriate care.<br> </p><p>Sincerely,<br>/s/<br>Stacey Hughes<br>Executive Vice President</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/aha-house-letter-supporting-improving-seniors-timely-access-to-care-act-5-21-2025.pdf" target="_blank" title="Click her to download the AHA House Letter Supporting Improving Seniors鈥� Timely Access to Care Act PDF.">Download the Letter PDF</a></div></div></div></div> Wed, 21 May 2025 13:05:17 -0500 Prior Authorization /news/headline/2025-03-20-study-finds-90-medicaid-managed-care-plans-cover-least-one-aud-medication-without-priority-and <p>A JAMA Network Open <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831362" target="_blank">study</a> published March 13 found that 90% of Medicaid managed care plans cover at least one alcohol use disorder medication without prior authorization and quantity limits. It also noted that while Medicaid managed care plans are the largest payer for addiction treatment services, approximately 43% cover all four AUD treatments approved by the Food and Drug Administration.  </p><p>鈥淭his study suggests that efforts to expand AUD medication prescribing may be limited by gaps in health insurance coverage,鈥� the study notes. 鈥淢edicaid MCPs and states can support AUD medication utilization by covering these medications without applying utilization management strategies.鈥� </p> Thu, 20 Mar 2025 14:49:33 -0500 Prior Authorization /news/headline/2025-02-12-report-highlights-how-health-care-can-avoid-20-billion-spending <p>The Council for Affordable Quality Healthcare Feb. 11 released a <a href="https://www.caqh.org/hubfs/Index/2024%20Index%20Report/CAQH_IndexReport_2024_FINAL.pdf">report</a>  highlighting how the health care industry can save $20 billion by transitioning from manual to electronic workflows.  <br>  <br>In addition, it found that the industry could save $515 million annually on electronic prior authorizations and save providers and staff 14 minutes per transaction.</p> Wed, 12 Feb 2025 16:06:21 -0600 Prior Authorization /news/headline/2025-01-29-kff-ma-insurers-made-nearly-50-million-prior-authorization-determinations-2023 <p>An <a href="https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/">analysis</a> by KFF released Jan. 28 found that Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. The finding reflects continued year-over-year increases from 2022 (42 million) and 2021 (37 million) as more people have enrolled in MA. KFF also found that in 2023 there was an average of nearly two prior authorization determinations per MA enrollee. <br><br>The analysis found that insurers fully or partially denied 3.2 million prior authorization requests (6.4%) in 2023, a smaller share than 2022 (7.4%). In 2023, 11.7% of denied prior authorization requests were appealed in MA and of those cases, 81.7% were partially or fully overturned.</p> Wed, 29 Jan 2025 15:38:18 -0600 Prior Authorization /news/headline/2024-12-17-aha-releases-final-health-care-plan-accountability-update-2024 <p>The AHA Dec. 17 released its Health Care Plan Accountability Update, covering the latest developments in Medicare Advantage, legislation and regulation of private health insurers, as well as other resources from the last quarter. <a href="/health-care-plan-accountability-update-december-2024">LEARN MORE</a> </p> Tue, 17 Dec 2024 14:54:17 -0600 Prior Authorization /news/headline/2024-10-17-senate-report-scrutinizes-medicare-advantage-prior-authorization-denials-post-acute-care-services <p>A <a href="https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf">report</a> released Oct. 17 by the Senate Homeland Security Committee鈥檚 investigative subcommittee scrutinizes some of the nation's largest Medicare Advantage insurers for their use of prior authorization and high rates of denials for certain types of care. The subcommittee sought documents and information from the three largest MA insurance companies 鈥� UnitedHealthcare, Humana and CVS 鈥� and investigated their practice of 鈥渋ntentionally using prior authorization to boost profits by targeting costly yet critical stays in post-acute care facilities.鈥�  <br><br>The report found that between 2019 and 2022, UHC, Humana and CVS denied prior authorization requests for post-acute care at far higher rates than other types of care. In 2022, UHC and CVS denied prior authorization requests for post-acute care at approximately three times higher than the companies' overall denial rates, while Humana's prior authorization denial rate for post-acute care was more than 16 times higher than its overall denial rate. The report also found increases in post-acute care service requests subjected to prior authorization and denial rates for long-term acute care hospitals, among other findings.</p> Thu, 17 Oct 2024 16:01:56 -0500 Prior Authorization /news/perspective/2024-09-20-increasing-administrative-costs-burdensome-commercial-insurer-practices-create-patient-care <p>There will always be administrative costs associated with operating a hospital. But the lion鈥檚 share of a hospital鈥檚 resources should be devoted to doing what hospitals do best: provide safe, accessible and exceptional patient care to anyone who needs it.</p><p>That may seem self-evident, but as documented in a <a href="/guidesreports/2024-09-10-skyrocketing-hospital-administrative-costs-burdensome-commercial-insurer-policies-are-impacting">new AHA report</a> released this month, that mission is coming under increasing strain because of skyrocketing administrative costs and burdensome commercial insurer practices that often delay and deny patient care.</p><p>For example, many commercial insurers now demand prior authorization for a growing array of services and the use of step therapy or 鈥渇ail-first policies鈥� that delay patients from getting the most appropriate care. Between 2022 and 2023, care denials increased an average of 20.2% for commercial claims and 55.7% for Medicare Advantage claims, according to the report.</p><p>These burdensome commercial insurer practices force hospitals and health systems to dedicate precious staff and clinical resources to appeal and overturn inappropriate denials 鈥� which alone can cost billions every year. In fact, recent data from Strata Decision Technology show that administrative costs now account for <strong>more than 40% of total expenses hospitals incur in delivering care to patients.</strong></p><p>Speaking for many in the field, one health system noted in our report that 鈥渢he growing number of prior authorization requirements, claim audits, denials, level of care downgrades and payer policies is staggering . . . affecting our health system鈥檚 ability to reinvest in its infrastructure, service lines, and physician retention and recruitment.鈥�</p><p>The goal of hospitals and care teams is to care for patients and bring them back to health, without being hobbled with excessive regulatory and insurer requirements that stand in the way of their critical work.</p><p>The AHA is leading the fight to push back against onerous and often inappropriate insurance tactics that burden already overwhelmed health care professionals and decrease patient access to care.</p><p>We have made commercial insurer accountability a top priority, working with Congress and the federal agencies to increase oversight of Medicare Advantage plans and crack down on abuses that undermine their effectiveness for patients. And we are making some progress. For example, earlier this year we worked closely with the Centers for Medicare & Medicaid Services to shape a final regulation requiring MA, Medicaid, Children's Health Insurance Program and federally facilitated Marketplace plans to streamline their prior authorization processes to improve timely access to care for patients and alleviate provider administrative burden.</p><p>At the same time, the Coalition to Strengthen America鈥檚 Healthcare, of which the AHA is a founding member, has launched a multiplatform media blitz in September, including debuting a new ad called <a href="https://www.youtube.com/watch?v=s504f02MW3I" target="_blank" title="Youtube: Every Second Counts">鈥淓very Second Counts.鈥�</a></p><p>The ad, which is running on national cable including Fox, CNN and MSNBC, draws the distinction between hospitals and health systems providing 24/7 care to patients and corporate health insurers that often delay needed care while increasing their profits.</p><p>We will continue speak out that clinicians and care teams in consultation with their patients should be the ones making critical care decisions 鈥� not insurers, regulators and bureaucrats.</p><p>Caregivers will never be deterred from their mission of providing quality and safe patient care. We will continue to collaborate with partners 鈥� both in and out of government 鈥� to address and remove any impediments to a hospital鈥檚 ability to do what they do best: treat patients, save lives and advance health for all.</p> Fri, 20 Sep 2024 08:08:52 -0500 Prior Authorization /news/headline/2024-09-17-aha-urges-hhs-oig-further-scrutinize-medicare-advantage-organizations-use-prior-authorization-post <p>The AHA Sept. 17 <a href="/lettercomment/2024-09-17-aha-hhs-oig-re-medicare-advantage-organizations-use-prior-authorization-post-acute-care" target="_blank">urged</a> the Department of Health and Human Services鈥� Office of Inspector General to further scrutinize policies and practices by certain Medicare Advantage Organizations (MAOs) that impede patient access to post-acute care and circumvent rules designed to ensure access and coverage parity between MA and Traditional Medicare. HHS OIG in June <a href="/news/headline/2024-07-03-hhs-announces-investigation-ma-prior-authorization-use-post-acute-care)" target="_blank">initially announced</a> it would examine MAOs' prior authorization denials for post-acute care after a qualifying hospital stay.  </p><p>"Hospitals and health systems continue to experience inappropriate denials and delays in care for MA beneficiaries consistent with the concerns raised by prior HHS OIG work that found MAOs sometimes denied prior authorization requests for post-acute care after a qualifying hospital stay even though the requests met Medicare coverage rules," AHA wrote. "As indicated by the mounting evidence of inappropriate insurer denials and delays of post-acute care services, further scrutiny of these practices is warranted. The AHA strongly supports investigation into and greater oversight of MAO practices, particularly as they pertain to access to post-acute care services."</p> Tue, 17 Sep 2024 15:15:59 -0500 Prior Authorization /lettercomment/2024-09-17-aha-hhs-oig-re-medicare-advantage-organizations-use-prior-authorization-post-acute-care <p>September 17, 2024 </p><p>The Honorable Christi A. Grimm Inspector General <br>U.S. Department of Health and Human Services <br>330 Independence Avenue, SW Washington, DC 20201 </p><p><em><strong>Re: Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care (Report Number OEI 09-24-00330)</strong></em></p><p>Dear Inspector General Grimm: </p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations and our clinician partners 鈥� including more than 270,000 affiliated physicians, two million nurses and other caregivers 鈥� and the 43,000 health care leaders who belong to our professional membership groups, the 黑料正能量 Association (AHA) applauds the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) for your recently announced review of <a href="https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp" target="_blank">Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care</a>. </p><p>The AHA continues to be concerned about the policies and practices of certain Medicare Advantage Organizations (MAOs) that impede patient access to care and circumvent rules designed to ensure access and coverage parity between Medicare Advantage (MA) and Traditional Medicare. Hospitals and health systems continue to experience inappropriate denials and delays in care for MA beneficiaries consistent with the concerns raised by prior <a href="https://oig.hhs.gov/documents/evaluation/3140/OEI-09-16-00410-Complete%20Report.pdf" target="_blank" title="Prior HHS OIG work">HHS OIG work</a> that found MAOs sometimes denied prior authorization requests for post-acute care after a qualifying hospital stay even though the requests met Medicare coverage rules. As indicated by the mounting evidence of inappropriate insurer denials and delays of post-acute care services, further scrutiny of these practices is warranted. The AHA strongly supports investigation into and greater oversight of MAO practices, particularly as they pertain to access to post-acute care services. </p><p>In the following sections, we describe the experience of referring hospitals and post-acute care providers with problematic MAO practices that inappropriately limit access to Medicare-covered post-acute care services and/or fail to comply with federal rules. <strong>As described below, these practices have, in some cases, caused direct and irreversible harm to patients, stymieing their recovery from serious illness or injury and hindering restoration of their functional capabilities</strong>. These abusive practices further strain health care delivery system resources and capacity at referring general acute-care hospitals by imposing days- or weeks-long delays in the necessary authorizations to transition patients to the next site of care, while sometimes precluding patient access to post-acute care sites altogether. <strong>We hope the experiences of patients, hospitals and health systems shared in this letter will inform your examination of MAO use of prior authorization for post-acute care services. We also hope it will spur greater action to curb practices that harm Medicare beneficiaries and unnecessarily delay timely access to care</strong>. On behalf of our members, we would be pleased to serve as a resource for any additional data, examples or information that would be helpful as you conduct your inquiry into this important topic. </p><p>We also want to acknowledge not all MA plans are the same; many have active partnerships with providers in service of their shared patients/members and consistently act in good faith to follow the rules. To this end, we believe that enforcement actions should be targeted to MA plans that have a history of suspected or actual violations or whose performance metrics related to appeals, grievances and denials could be indicative of a broader problem warranting investigation. Every effort should be made in carrying out enforcement activities to ensure that undue burden is not placed upon MA plans that consistently act in good faith and adhere to federal rules.</p><p>View the details below.</p> Tue, 17 Sep 2024 14:47:18 -0500 Prior Authorization