A bipartisan collective of legislators wants to put forth a bill in Congress to streamline the prior authorization process in order to facilitate faster, lower-cost care. Since those are the same key attributes that continue to fuel the growth of urgent care, on the surface it might sound like the bill could boost our industry. Not so fast. According to congressional staff working behind the scenes, as quoted in an article published by MedPage Today, the bill would rely on Medicare Advantage (MA) organizations and providers to use “certain technologies to facilitate the administration of prior authorization requirements under [MA] plans offered by such organizations.” The way MA plans are set up currently, there is typically a “gatekeeper” primary care physician who must be the plan member’s point of contact for all things health-related; if the patient wants to see a specialist—or visit an urgent care center—the gatekeeper PCP has to give the green light. In effect, people who choose an HMO are trading personal choice for cost savings. Obviously, this is not conducive to true on-demand care. Further, the gatekeeper PCP is incentivized financially to help control total costs for the payer. The impact for urgent care is that it is by definition on-demand, and the gatekeeper PCP has no incentive to grant authorization—in fact, they lose money when they do so. That leaves the emergency room as the only on-demand option for HMO members. And we all know the cost savings to be realized there (ie, none). Small wonder, then, that a spokesperson for America’s Health Insurance Plans (AHIP) was quoted in the MedPage Today article as acknowledging “there is still work to be done to improve the process.” The bill is expected to be introduced in the House of Representatives this summer.

What the Proposed Prior Authorization Bill Could Mean for Urgent Care
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