A House committee voted 42 to 0 on July 15 to advance the Improving Seniors’ Timely Access to Care Act, pushing a Medicare Advantage prior-authorization overhaul toward its first floor vote since an earlier version passed the House unanimously and then stalled in the Senate. The bill would force Medicare Advantage insurers to build an electronic system for prior-authorization requests, replacing the faxes and phone holds that now delay approval for care physicians already expect to get covered. Behind the vote sits a federal audit, published weeks earlier, finding insurers overturn most of their own denials once a beneficiary or provider actually appeals.
A 95 Percent Reversal Rate on Nursing-Home Care Denials
The Department of Health and Human Services’ inspector general reported on June 8 that 19 Medicare Advantage organizations denied 12 percent of requests to admit a patient to a skilled nursing facility in June 2024, with individual insurers’ denial rates ranging from 0.4 percent to 23 percent. Enrollees and their providers appealed only 18 percent of those denials. When they did appeal, the insurers reversed themselves 95 percent of the time, a rate the inspector general called evidence that some enrollees were initially denied medically necessary care.
The pattern was worse where a contractor rather than the insurer made the initial call. NaviHealth, a subsidiary of UnitedHealth Group that processed half of all skilled-nursing-facility requests in the review, denied 14 percent of them, compared with 11 percent for insurers handling requests internally and 9 percent for other contractors. Appealed naviHealth denials were overturned 97 percent of the time. Nursing-home residents seeking a covered stay were denied 40 percent of the time, nearly four times the 11 percent rate for other enrollees, a gap the inspector general flagged for further review rather than explained.
The finding echoes an earlier audit that found insurers overturned 75 percent of appealed preauthorization and payment denials industry-wide, reversing about 216,000 denials a year, while beneficiaries appealed only 1 percent of denials in the first place. CMS agreed at the time to give beneficiaries clearer information about serious violations by insurers; the inspector general’s own tracker still lists that recommendation as open and unimplemented. Eight years and a second audit later, the appeal rate barely moved and the reversal rate, at least for nursing-home admissions, climbed higher.
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Electronic Prior Authorization, Reporting, and Response-Time Rules
The bill, sponsored by Reps. Mike Kelly of Pennsylvania, Suzan DelBene of Washington, John Joyce of Pennsylvania and Ami Bera of California, would require every Medicare Advantage plan to build an electronic prior-authorization program with standardized transactions and clinical attachments, according to the Congressional Research Service’s summary of the legislation. Plans would have to report annually to the Centers for Medicare and Medicaid Services on what share of requests they approve and how long responses take, and CMS would publish that data for every plan.
The bill also directs HHS to set enforceable response-time standards, including for expedited requests and for services that are routinely approved anyway, the category most likely to cover a nursing-home admission after a hospital stay, the exact gap the inspector general’s skilled-nursing review measured. CMS and the Office of the National Coordinator for Health Information Technology would separately study whether real-time decisions are feasible and whether insurers’ growing use of artificial intelligence in making those decisions is affecting beneficiaries’ access to care.
None of those requirements are in effect. The bill has not passed either chamber of the current Congress, and the electronic system, reporting obligations and response-time rules it describes only take hold once it is signed into law and HHS writes the implementing regulations that would follow. That gap matters: the 2018 recommendation that CMS give beneficiaries clearer information about serious insurer violations took years to close, and a companion recommendation from the same audit remains unimplemented, a reminder that a signed law is not the same as an enforced one.
A Second Attempt After a Senate Stall
The legislation has been here before. An earlier version passed the House unanimously in the 117th Congress after collecting cosponsorships from a majority of the House and Senate, only to expire when the Senate never brought it to a vote. Its sponsors reintroduced the bill in the current Congress, and it has since drawn 290 House cosponsors, a bipartisan supermajority large enough, on paper, to pass the floor if leadership schedules a vote.
The July 15 committee action, ordered to be reported in the nature of a substitute by a unanimous 42-0 vote, moved the bill roughly a quarter of the way through the legislative process, past the committee stage that has stalled other prior-authorization bills in recent sessions. It still needs a floor vote in the House, Senate action and a presidential signature before any Medicare Advantage plan is legally required to change how it processes a single request.
For an enrollee weighing a knee replacement, a nursing-home stay after surgery, or home health following a hospitalization, the inspector general’s numbers are the more immediate reality: an insurer’s first answer carries roughly a one-in-nine to one-in-five chance of being wrong by the insurer’s own later admission, and only a fraction of denied beneficiaries ever contest it. The bill moving through the House would not change medical necessity standards or coverage rules; it would only speed up and standardize how fast an insurer has to answer, and how much of its record becomes public in the process.
This article was researched and drafted with the assistance of artificial intelligence.
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