Overview
Recently, the House Ways & Means Health and Oversight Subcommittees held a joint hearing titled “Medicare Advantage: Past Lessons, Present Insights, Future Opportunities.” Lawmakers on both sides of the aisle expressed frustration with the current state of the Medicare Advantage (MA) program. While acknowledging its popularity among seniors, members from both parties pointed to deep concerns about delays in care due to prior authorization, inflated risk coding, and a lack of effective oversight. The hearing made clear that significant reforms are under consideration, though no consensus has yet emerged.
Prior authorization
A central focus of the hearing was the impact of prior authorization requirements in MA plans. Witnesses and lawmakers described the system as slow, unpredictable, and overly complex. Delays in approvals are leading to postponed or denied care, particularly harming patients with time-sensitive needs. Proposals to automate the process using artificial intelligence were met with caution, as critics warned that technology could worsen denial rates if not carefully regulated. While some MA plans have voluntarily pledged to reduce prior authorizations, those efforts are not yet translating into meaningful change in reality.
Risk coding and overspending
Concerns over upcoding, where MA plans assign patients higher risk scores than appropriate, were repeatedly raised. These inflated scores lead to higher federal payments, costing the Medicare program billions in unnecessary spending. The Medicare Payment Advisory Commission (MedPAC) estimates MA plans will be paid 20% more per enrollee in 2025 than if those same individuals were in traditional Medicare. Reform advocates argued that reducing overpayments could help fund improvements in other areas of the health care system, including payments to allergists.
Rural impact and provider participation
The hearing also examined how MA affects rural providers and patients. Although enrollment in MA is growing in rural areas, many providers in these regions are opting out of participation due to low reimbursement rates, administrative burdens, and staffing challenges. Smaller hospitals and practices often lack the personnel needed to navigate complex prior authorization processes. Some rural patients face fewer plan choices and longer wait times for care. Telehealth and transportation benefits were cited as potentially helpful features, but these offerings are not yet widespread or consistent across plans.
Legislation and potential reform
Several legislative proposals are under consideration to address the problems raised in the hearing.
The Prompt and Fair Pay Act, introduced by Rep. Lloyd Doggett (D-TX-37) and co-sponsored by Rep. Greg Murphy (R-NC-3), would require MA plans to reimburse providers at least at traditional Medicare rates and enforce prompt payment standards for clean in-network claims. ACAAI’s Advocacy Council has endorsed this legislation.
The Improving Seniors’ Timely Access to Care Act (H.R. 3514) would streamline the prior authorization process across MA plans and could become part of a larger bipartisan package later this year. The Advocacy Council has consistently supported this legislation in the past and will continue to do so in the future.
Additionally, Rep. Judy Chu (D-CA-28) is preparing legislation that would increase transparency around the use of artificial intelligence in prior authorization decisions. The bill is expected to require disclosure of how AI tools are used to approve or deny care and places guardrails to prevent automated systems from driving denials without human oversight.
These measures reflect a growing concern that AI, if left unchecked, could worsen access issues rather than improve them.
What this means for allergists
Allergists should anticipate continued administrative complexity when dealing with MA plans, particularly concerning prior authorization. Delays in care are likely to persist unless future legislation enforces standardization or stronger oversight. Reimbursement structures could shift, especially if bills linking MA payments to traditional Medicare gain traction. Additionally, increased scrutiny of coding practices may lead to more frequent audits or documentation requirements. Practices in rural areas may continue to face added strain due to limited staffing and a lack of negotiating power.
Conclusion
This hearing potentially marks a turning point in congressional oversight of Medicare Advantage. While there is no immediate path forward, the bipartisan tone and range of concerns raised suggest that reforms are gaining traction. The Advocacy Council will actively oversee and evaluate policy developments that may affect reimbursement, prior authorization, and participation in MA plans.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
