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Policy background information

Prior authorization


The American Academy of Dermatology Association (AADA) supports the Improving Seniors’ Timely Access to Care Act (H.R. 3107), which would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization in the Medicare Advantage program.

Message to Capitol Hill

Prior authorization is a significant barrier to care that has harmed the patient-physician relationship by placing a third party in a decision-making position, with no knowledge of the complexity or full history of a patient’s condition. These policies are not only inappropriate but also impede a patient’s access to the most effective therapies and medical services. This delay can cause irreparable harm to patients in need of a proper treatment plan.

The AADA has long advocated for solutions that remove this hindrance to effective patient care. As dermatologists, we have the expertise and apply our understanding of the often complex interplay of factors in making a treatment determination that works best for a specific patient. The clinically indicated choice of therapy and medical services is critical to positive outcomes and rests on the physician-patient relationship.

Prior authorization and their associated appeals policies should not encroach on or unduly burden physicians or patients in accessing optimal, medically necessary treatments and services.

Ask

Cosponsor and support passage of the Improving Seniors’ Timely Access to Care Act (H.R. 3107) prior to the close of the 116th Congress.

Background

Introduced by Reps. Suzan DelBene, D-WA, Mike Kelly, R-PA, Roger Marshall, MD, R-KS, and Ami Bera, MD, D-CA, the Improving Seniors’ Timely Access to Care Act (H.R. 3107) would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program, providing much-needed oversight and transparency of health insurance for America’s seniors. Based on a consensus statement on prior authorization reform adopted by leading national organizations representing physicians, medical groups, hospitals, pharmacists, and health plans, the legislation would facilitate electronic prior authorization, improve transparency for beneficiaries and providers alike, and increase Centers for Medicare & Medicaid Services (CMS) oversight of how Medicare Advantage plans use prior authorization.

Specifically, the Improving Seniors’ Timely Access to Care Act would:

  • Create an electronic prior authorization program including the electronic transmission of prior authorization requests and responses and a real-time process for items and services that are routinely approved.

  • Improve transparency by requiring plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials.

  • Require plans to adopt transparent prior authorization programs that are reviewed annually, adhere to evidence-based medical guidelines, and include continuity of care for individuals transitioning between coverage policies to minimize any disruption in care.

  • Hold plans accountable for making timely prior authorization determinations and to provide rationales for denials; and

  • Prohibit additional prior authorization for medically necessary services performed during a surgical or invasive procedure that already received, or did not initially require, prior authorization.

More information

Treatment decisions are best made by physicians in consultation with their patients. Learn more about the impact prior authorization has on dermatologic care.


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