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Thursday, September 15, 2022

H.R. 3173, Medicare Prior Authorization

Insurers offering Medicare Advantage plans requiring prior authorization would have to establish an electronic authorization program and meet new standards for decision timing and transparency under a modified version of H.R. 3173.

The Health and Human Services Department would have to approve the electronic authorization programs and would also set time frames and transparency requirements for prior authorization decisions for Medicare Advantage plans.

Medicare Advantage plans allow individuals to obtain coverage normally provided through Part A (hospital) and Part B (medically necessary and preventive services) from approved private insurers.

MA plans, like other insurance plans, often require health care providers to obtain prior authorization for certain medical treatments before they can treat patients. In a September 2018 report, HHS’ Office of Inspector General found that MA plans overturned 75% of their denials for preauthorization — raising concerns that some MA beneficiaries and providers were initially denied services and payments that were medically necessary.
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