Legislative Action Center

Approximately 54% of Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans which are managed by private insurance companies under the umbrella of the overall Medicare program administered by CMS. Once enrolled in an MA plan, beneficiaries are bound by their rules which are generally more limiting than traditional Medicare Fee-For-Service (FFS) options. While MA plans may offer additional benefits, healthcare providers including occupational therapy practitioners (OTPs) frequently report burdensome paperwork requirements, complicated claims processes, delayed payments, low reimbursement rates, and often strict prior authorization requirements that limit access to OT services for MA beneficiaries.

To address some of these issues, Reps. Lloyd Doggett (D-TX) and Greg Murphy, MD (R-NC) have introduced the Prompt and Fair Pay Act (H.R.4559) which would ensure that Medicare Advantage payments for OT and other services at least match Medicare FFS reimbursement levels while also requiring prompt payment of clean claims and enhanced transparency from MA organizations regarding questioned claims. Reps. Doggett and Murphy both referred to significant issues with MA reimbursement and administrative burden during a Ways and Means Health Subcommittee hearing in July 2025, noting that a few major MA organizations are responsible for the majority of the issues faced by beneficiaries and providers.

AOTA has endorsed H.R.4559 which would address issues AOTA members have reported including low reimbursement, delays in payment, and erratic procedures for handling questioned claims. These changes are crucial to reduce the administrative burden related to MA claims and would allow a greater focus on actual patient care.

Contact your Representative to urge them to co-sponsor H.R.4559 and to work to ensure fair reimbursement for occupational therapy and other services.

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