Nathaniel Moran Bemoans 'Really Unworkable' Prior Authorization Rules For Medicare Advantage

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During a House Ways and Means Committee heairng prior to the congressional recess, Rep. Nathaniel Moran (R-TX) spoke about Medicare Advantage's prior authorizations.

Transcript

00:00I now recognize Mr. Moran.

00:02Thank you, Mr. Chairman, for this very valuable hearing today about Medicare Advantage.

00:07From background for our witnesses, I want you to know I represent the 1st Congressional District of Texas,

00:11where just over 83,000 of my constituents have chosen to enroll in Medicare Advantage plans.

00:18That's roughly 48.6% of Medicare-eligible individuals in my district.

00:23As I travel through my district, which is very rural,

00:26I hear a lot of struggles faced by many in the Medicare Advantage plans.

00:31These struggles are not unique to my district, but they are exacerbated by the fact that I am in a rural community.

00:38That's why I think this hearing is very important today,

00:40so that we can figure out how to make the changes we need to make

00:44so that Medicare Advantage works appropriately when chosen by our constituents.

00:51The number one difficulty that I hear about is that providers are forced to navigate

00:55these prior authorization rules that are really unworkable oftentimes,

01:00that create delays or denials for medically necessary care.

01:04Continual prior authorization denials require, as you guys know,

01:08a significant amount of staff time to appeal the denials,

01:10which pull staff away from their intended goal of providing care.

01:14Dr. Miller, in your written testimony, you mentioned, quote,

01:18quote, the significant administrative and documentation burden resulting in burnout

01:23as it relates to prior authorizations.

01:25From your experience, how might the administrative burdens associated with prior authorization

01:29impact the work of physicians and staff?

01:33So I think prior authorization makes it harder to be a physician,

01:37but it also recognizes that physicians don't always make the right choice.

01:42I mean, I'd like to think that I do or my colleagues, most of the time we get it right,

01:47some of the time we don't get it right.

01:49Having to resubmit paperwork, having to send in a fax,

01:54having to call someone and voice dictate, as one of my colleagues here mentioned, is nonsensical.

02:00There's nothing wrong with having prior authorization as a process.

02:06Every other insurance market has that, whether it's Medicaid,

02:08whether it's the ACA exchange plans, whether it's employer-sponsored insurance,

02:13the only place that does not have prior authorization in a meaningful form is fee-for-service Medicare,

02:19until, of course, the introduction of a new CMS Innovation Center model recently.

02:25But prior authorization is something where we need to make it easy for clinicians and hospitals

02:32and other providers to get the data into the plan,

02:35make it clear what the criteria are at the point of care,

02:39and then automate approval.

02:41I know that other members had expressed concern about AI.

02:45We should use AI to make the process more efficient.

02:48If I can automate prior approval for a drug, a surgery, an imaging study,

02:54that is a win, and we need to make that the default.

02:57Dr. Basil, you mentioned in your testimony items relating to the prior authorization issue as well,

03:04in particular about post-acute care, which generally results in longer hospital stays

03:09that are costly when the prior authorizations don't come through.

03:11I can tell you I heard from a number of my home health groups back in the district

03:15who shared stories where they were unable to provide care

03:18because the prior authorizations would have taken too long,

03:21and they simply had to move on to other patients.

03:23I want to ask you, Dr. Basil, what impact does this have on the care patients desperately need,

03:29the costs associated with the care ultimately received,

03:32and what needs to change in this process to correct these issues?

03:36So I would agree with the general themes kind of of the day.

03:39It's going to be transparency and consistency,

03:42consistency between plans and the transparency in how these decisions are made

03:46and the repeatability of that decision every time.

03:50I totally agree with those.

03:52Just from a, you mentioned, home health standpoint, you know, as a faith-based institution,

03:57you know, we go ahead and send people to the appropriate level of care,

04:00and if that ends up getting denied, we just have to eat that.

04:02And so we've made the decision, you know, from a corporate standpoint

04:06that we're just going to go ahead and do the right thing clinically

04:08and let the rest of that sort out.

04:11But it is certainly an issue.

04:12Ms. Moroney, I want to come to you on the last question

04:15because the issue of transparency was just mentioned,

04:17and I believe transparency is really one of the foundations for trust in any situation,

04:22but particularly here.

04:24We need more transparency for our beneficiaries, I think,

04:27to be aware of the potential supplemental benefits that are out there,

04:30accessibility of providers, potential prior authorization issues

04:33that might come up with respect to certain procedures.

04:37In your opinion, you mentioned in your testimony that you emphasized, again,

04:41that Medicare beneficiaries trust us.

04:43Again, I think trust and transparency are related.

04:46How might increased transparency in these areas that I mentioned and others,

04:50from health plans to providers and beneficiaries,

04:53ensure that plans are delivering the services they advertise to beneficiaries

04:57and that trust is delivered?

04:59If I think about just supplementals,

05:02it would be great to have readily available public data specifically produced by CMS

05:08about supplementals and the utilization around that for all payers and all plans

05:13so that as you're designing a unique plan in the future,

05:16you're designing it directly to the consumers

05:19and what their absolute needs are specifically.

05:22In addition, prior authorizations,

05:25you can publicize that data specifically on the plans

05:28and their utilization rates

05:30and then put that in a system directly to beneficiaries

05:33to know who is offering improvements in this area

05:37to create competition and more choice for beneficiaries.

05:41Thank you to the panel.

05:42Mr. Chairman, I yield back.

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