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AAOS News
Prior Authorization Bill Reaches Important Milestone
On May 11, the AAOS-endorsed Improving Seniors’ Timely Access to Care Act—which would reform the burdensome prior authorization process within Medicare Advantage—accumulated 294 bipartisan cosponsors in the U.S. House of Representatives. A rule recently implemented in the House of Representatives allows for pieces of legislation that have amassed over 290 cosponsors to be added to the House floor ‘consensus calendar’ and bypass committee action. AAOS and the bill’s lead sponsors are still urging for a hearing in Ways & Means to ensure regular order, but the 290 number is expected to push the committee towards swift action. This milestone follows a report from HHS’ Office of Inspector General citing the prior authorization abuses made by Medicare Advantage organizations as well as a Senate report showing how critical prior authorization reforms would be to help patients with mental health needs.
Congress Introduces Legislation Reauthorizing Food and Drug Administration User Fees
On May 6, bipartisan House Energy and Commerce Health Subcommittee leadership released The Food and Drug Amendments of 2022 to reauthorize the Food and Drug Administration (FDA) medical product user fee programs for the next five years. Current user fee authorizations expire on September 30. The bill would reauthorize the Prescription Drug User Fee Act, Generic Drug User Fee Act, Biosimilar User Fee Act, and Medical Device User Fee Act. It also contains provisions to improve the FDA’s accelerated approval pathway, increase clinical trial diversity, strengthen generic drug competition, and support the medical supply chain through FDA’s inspections programs. The FDA would also be given the authority to require that manufacturers submit diversity action plans to incorporate diverse populations in their clinical trials. Lawmakers aim to have the package sent to the President for his signature by August.
Medicare Advantage Plans Improperly Denied 85,000 Prior Authorization Requests
In April, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) released a report that found Medicare Advantage Organizations (MAOs) improperly denied up to 85,000 prior authorization requests in 2019 alone. The report found that MAOs often used additional internal criteria that weren’t included in Medicare coverage rules or had additional documentation requirements that allowed them to deny prior authorization requests. In addition to improper prior authorization denials, nearly 20% of reimbursement payments were denied despite meeting Medicare coverage rules. The report included dozens of individual examples of improper denials for orthopaedic patients, including wrongful denials of MRIs, shoulder and knee x-rays, inpatient admission, rehab admission, durable medical equipment, follow-up visits, and joint injections. One patient detailed in the report requested a reverse total shoulder replacement but was denied for not meeting “internal criteria.” The OIG determined the surgery was warranted, and yet the initial denial was not reversed on appeal. The AAOS-endorsed Improving Seniors’ Timely Access to Care Act aims to reform the prior authorization process within Medicare Advantage plans and has garnered over 300 congressional supporters. |
