Bill > HR5213

This bill, the Reducing Medically Unnecessary Delays in Care Act of 2023, aims to ensure that prior authorization medical decisions under Medicare are made by physicians. The key provisions include: 1. Requiring Medicare administrative contractors, Medicare Advantage plans, and prescription drug plans to base any restrictions, preauthorizations, or adverse determinations on the medical necessity or appropriateness of the service and written clinical criteria. 2. Prohibiting the denial of coverage solely on the grounds that a health care service does not meet an evidence-based standard, if no such standard exists. 3. Mandating that the plans obtain input from actively practicing, board-certified physicians who are not their employees when establishing or materially altering written clinical criteria for preauthorization review. 4. Specifying requirements for the written clinical criteria, such as being based on nationally recognized standards, developed in accordance with accreditation entities, and evaluated and updated annually. 5. Requiring the plans to make preauthorization requirements and restrictions readily accessible on their websites, described in detail but in easily understandable language. 6. Obligating the plans to provide contracted health care providers with written notice of any new or amended preauthorization requirements or restrictions at least 60 days before implementation. 7. Mandating the plans to make statistics on preauthorization approvals and denials available on their websites, including categories for physician specialty, medication or procedure, indication, and reason for denial. 8. Ensuring that all preauthorizations and adverse determinations are made by a physician who is board-certified or eligible in the same specialty as the provider typically managing the condition or providing the service.