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In a June 2019 sample of denials issued by 15 of the largest Medicare Advantage insurers, OIG found that 18 percent of denied payments and 13 percent of denied prior authorizations met Medicare coverage rules— i.e., services that would have likely been approved for beneficiaries under Medicare fee-for-service.

The American Medical Association agrees with the federal investigators’ recommendations for preventing inappropriate use of authorization controls to delay, deny and disrupt patient care, but more needs to be done to reform prior authorization. To rein in excessive and unnecessary prior authorization requirements and improve care delivery for America’s seniors, the AMA supports The Improving Seniors’ Timely Access to Care Act (HR 3173 / S 3018), which would require Medicare Advantage plans to streamline and standardize prior authorization processes and improve the transparency of requirements. The proposed federal legislation has gained bipartisan support from more than 300 members in both chambers of Congress. The time is now for federal lawmakers to act to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.

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