S. 3762: Prior Authorization Relief Act

This bill, known as the Prior Authorization Relief Act, aims to reform the prior authorization process within the Medicare Advantage program. Here’s how it would work:

Audit of Prior Authorization Requirements

The bill mandates that by January 1, 2027, the Secretary of Health and Human Services must conduct an audit of the prior authorization requirements for various items and services provided to Medicare Advantage enrollees. This audit will focus on:

• Items and services that are among the top 10 percent in terms of reimbursement costs.
• Items and services that have sufficient clinical evidence to create a standard medical policy for prior authorization.
• Items and services for which the prior authorization process is considered excessively complicated or requires too many steps.

Establishment of Standardized Requirements

Following the audit, by May 1, 2028, the Secretary will issue a final rule to standardize the prior authorization requirements for the audited items and services across all Medicare Advantage plans. This standardization will also apply to supplemental forms needed for prior authorization.

Exemptions from Prior Authorization Requirements

The bill includes a provision that the prior authorization requirements will not apply to specific items and services if they are provided by or prescribed by a provider who is involved in certain risk-sharing models, such as:

• Accountable Care Organizations (ACOs)
• Two-sided risk models that involve both potential gains and losses.

However, there is a limitation where Medicare Advantage organizations can request that the prior authorization requirements still apply for certain items and services, even if they are provided by these risk-sharing providers.

Overall Impact

The bill is designed to streamline the prior authorization process for Medicare Advantage enrollees, potentially making it easier for them to access needed services and medications. By conducting audits and establishing standardized practices, the intent is to reduce bureaucratic hurdles and improve overall efficiency in the healthcare system under Medicare Advantage.

Relevant Companies

• UNH - UnitedHealth Group: As a major provider of Medicare Advantage plans, changes in prior authorization rules may significantly impact their operational processes and service delivery.
• ANTM - Anthem, Inc.: Another major player in Medicare Advantage, this company would need to adapt its prior authorization protocols to comply with the new standards.
• CNC - Centene Corporation: As a provider of Medicare Advantage services, the bill may influence their administrative procedures regarding prior authorizations.