Bipartisan proposals have been floated but are yet to pass, with widespread support for these reforms from various organizations, including the American Medical Association. Lawmakers are raising concerns regarding MA plans’ strategies for delaying or denying payments and the need for stricter CMS oversight.
Federal lawmakers urge CMS to increase oversight of MA plans, particularly those “inventing new strategies” like concurrent reviews, pre-payment audits, and payment integrity administrative reviews to delay or deny care and reduce payments to providers. They call on CMS to require plans to publicly report data on prior authorization use, including the types of care, denial and appeal rates, and the vendors, algorithms, or AI tools used.
These calls come despite CMS releasing final regulations in January, 2024 as part of its Interoperability and Prior Authorization final rule. These rules require MA plans to respond to expedited prior authorization requests within 72 hours and standard requests within seven calendar days. This rule is slated for implementation by CMS in January 2026.
Congress advanced legislation to regulate Medicare Advantage with support from 60 Senate co-sponsors and 230 House co-sponsors, yet failed to pass the legislation before adjourning for the year. Legislation has been re-introduced in March, 2025.
Stulick, A., (2025, May 23). Bill aims to crack down on Medicare advantage prior authorizations for LTC, including nursing homes. Skilled Nursing News. https://skillednursingnews.com/2025/05/bipartisan-bill-aims-to-crack-down-on-medicare-advantage-prior-authorizations-for-ltc-including-nursing-homes/
Healy, A. (2025, May 22). Home care advocates slam ‘radical, detrimental’ MA overhaul bill. McKnights Home Care. https://www.mcknightshomecare.com/news/home-care-advocates-slam-radical-detrimental-ma-overhaul-bill/
Parker, J., (2025, May 21). ‘Ill-Conceived’: Proposed bill would require Medicare advantage to pay for hospice care. Skilled Nursing News. https://skillednursingnews.com/2025/05/proposed-bill-would-require-medicare-advantage-to-pay-for-hospice-care/
Senators reintroduce bill that seeks to reform prior authorization in Medicare Advantage. (2025, May 21). Fierce Healthcare. https://www.fiercehealthcare.com/regulatory/senators-reintroduce-bill-seeks-reform-prior-auth-ma
Stulick, A., (2025, March 28). Nursing home relief: Bipartisan bill aims to reform prior auth among Medicare advantage plans. Skilled Nursing News. https://skillednursingnews.com/2025/03/nursing-home-relief-bipartisan-bill-aims-to-reform-prior-auth-among-medicare-advantage-plans/
Rowan, K. (2025, January 9). Congress allows Medicare advantage to deny coverage. The Rowan Report. https://www.therowanreport.com/2025/01/09/congress-allows-medicare-advantage-to-deny-coverage/
Prior Auth Champions Celebrate over 500 Endorsements of the Improving Seniors’ Timely Access to Care Act. (2024, December 13). U.S. Congresswoman Suzan DelBene. https://delbene.house.gov/news/documentsingle.aspx?DocumentID=4001
American Medical Association & American Medical Association. (2024, November 12). Legislative action needed when insurers won’t pay for preauthorized care. American Medical Association. https://www.ama-assn.org/press-center/ama-press-releases/legislative-action-needed-when-insurers-won-t-pay-preauthorized
Marselas, K. (2024, November 1). Lawmakers to CMS: Monitor Medicare Advantage plans ‘inventing new strategies’ to delay payments to providers. McKnight’s Long-Term Care News. https://www.mcknights.com/news/lawmakers-to-cms-monitor-medicare-advantage-plans-inventing-new-strategies-to-delay-payments-to-providers/
Letter to the honorable Chiquita Brooks-LaSure, Administrator, Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services. (2024). https://www.finance.senate.gov/imo/media/doc/102924_wyden_neal_pallone_letter_to_cms_about_ma.pdf
Shryer, D. (2024, June 17). Providers express support for MA prior authorization reform bill – McKnight’s Long-Term Care News. McKnight’s Long-Term Care News. https://www.mcknights.com/news/providers-express-support-for-ma-prior-authorization-reform-bill/
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