CMS May Be Adding to Prior Authorization Problem

CMS proposes adding prior authorization for more services in calendar year 2023, according to the recently released outpatient prospective payment system (OPPS) proposed rule.

CMS recently released the OPPS proposed rule that would increase Medicare hospital outpatient payment rates by a net 2.7% in calendar year 2023 compared to 2022.

Also in the rule, is CMS' proposal to require prior authorization for an additional service category: facet joint injections and nerve destruction.

According to CMS this proposal would ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments. This would happen without adding new documentation requirements for providers, CMS says.

While CMS says it will ensure that this measure will not burden patients or providers, many are not so sure, since, as the American Medical Association previously found, prior authorizations of medical treatments and services has a negative impact on patients and physicians.

The recent survey featured 40 questions that were administered online last year. More than 1,000 practicing physicians participated in the survey, with 40% working as primary care physicians and 60% working as specialists.

The survey features several key data points.

• 93% of physicians reported that prior authorization led to delays of necessary care (14% always, 42% often, and 38% sometimes)
• 82% of physicians reported that the prior authorization process leads patients to abandon treatment (3% always, 24% often, 55% sometimes)
• 34% of physicians reported that prior authorization has led to a serious adverse event for a patient
• 24% of physicians reported that prior authorization has led to a patient's hospitalization
• 18% of physicians reported that prior authorization has led to a life-threatening event or required intervention to prevent permanent impairment or damage
• 29% of physicians reported that prior authorization criteria are rarely or never evidence-based
• Physicians and their staff spend an average of 13 hours per week processing prior authorizations
• 40% of physicians reported having staff who work exclusively on prior authorizations
• 88% of physicians reported that the administrative burden associated with prior authorization is high or extremely high
• 51% of physicians reported that prior authorization has interfered with a patient's ability to perform his or her job responsibilities

CMS will accept comments on the proposed rule through September 13.