AHA Letter on Prior Authorization Bill Introduced in Senate

December 17, 2020

The Honorable Sherrod Brown
United States Senate
503 Hart Senate Office Building
Washington, DC 20510

Dear Senator Brown:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners, including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates your work on the Improving Seniors’ Timely Access to Care Act of 2020. Your bipartisan legislation makes tremendous strides toward streamlining the prior authorization process, and we look forward to working with you in the next Congress to address this critical issue for patients and providers.

Prior authorization is a tool that can help align patients’ care with their health plan benefit structure and facilitate alignment with clinical best practices when used appropriately. However, these processes vary widely among health plans and insurers, and the lack of standardization can be confusing and burdensome for providers. Unfortunately, certain health plan utilization management practices can, when poorly structured or implemented, create unnecessary delays in care that can negatively affect patients.

America’s hospitals and health systems are committed to ensuring patient access to the highest quality care in a timely manner. Your bill takes important steps to streamline and improve prior authorization processes, which would help providers spend more time on patients instead of paperwork. As you move forward in the legislative process next year, we look forward to working with you to continue strengthening this important legislation. In particular, we recommend including response timelines in the legislation so that patients are ensured prompt access to care. We are concerned that deference to the Health and Human Services Secretary may lead to excessively long timelines like those provided in the recent proposed rule from the Centers for Medicare & Medicaid Services on prior authorization for Medicaid, Children’s Health Insurance Program and federally facilitated exchange plans.

We also would appreciate your consideration of requiring plans to share their criteria for making prior authorization decisions without exceptions. Providers cannot effectively comply with submission requirements if plans can classify their prior authorization criteria as proprietary. Transparency of the prior authorization requirements would ensure improved access to care for patients and significantly reduce administrative burden on providers.

Finally, we recommend further strengthening the legislation’s reporting requirements. As standard practice, plans do not share their prior authorization criteria with providers and then claim providers did not submit all of the necessary information. We recommend language to require plans to report on their decision timelines even when the provider’s request does not contain all information required. Reporting that allows plans to exclude data when providers do not submit all required information creates a misleading picture since plans are typically responsible for a provider’s inability to submit accurate information.

We commend you for your focus on this important issue and look forward to working with you to make improvements to the prior authorization process to ensure patient access to care.

Sincerely,

/s/

Thomas P. Nickels
Executive Vice President

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