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Prior Auths 'Delay, Deny, And Disrupt': Major Medical Societies Show Support for Reform

Analysis  |  By Amanda Norris  
   February 21, 2023

118 leading medical societies united to defend proposed prior authorization reforms.

The organizations, spanning from the American Medical Association to The Alaska State Medical Association, sent a letter to CMS urging it to finalize proposed prior authorization reforms that target the inappropriate use of authorization requirements by Medicare Advantage plans which, the organizations say, delay, deny, and disrupt the provision of medically necessary care to patients.

"Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians," said American Medical Association President Jack Resneck Jr, in a recent press release.

"We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments," Resneck said.

According to the letter, reforms proposed by CMS must be implemented amid mounting evidence that Medicare Advantage plans are delaying or even preventing Medicare beneficiaries from getting optimal care, resulting in alarming effects on patient health.

Because of this reason and more, the MGMA told HealthLeaders that the organizations have four key asks of CMS:

  1. Finalize many of the prior authorization proposals in this rule that address long-established concerns
  2. Apply the proposed clinical validity and transparency of coverage criteria policies beyond the current scope to include prescription drugs
  3. Establish and implement an oversight plan that will hold plans accountable for noncompliance
  4. Include additional prior authorization reforms in future rulemaking, such as eliminating step therapy, requiring gold-carding programs, and exempting medical groups participating in value-based models from prior authorization requirements

 

In the letter, the organizations pointed to three studies highlighting the prior authorization burden. According to the letter:

  • A recent survey found more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care. More than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers, and more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.
  • The OIG found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments, in some cases ignoring prior authorizations or other documentation necessary to support the payment.
  • A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about 6% of the 35 million requests submitted in 2021. While about 11% of denials were appealed, the vast majority (82%) of appealed denials were fully or partially overturned, raising serious concerns about the appropriateness of many of the initial denials.

For background, CMS proposed a rule in December 2022 to streamline the administrative process by requiring Medicare Advantage plans to implement electronic prior authorization.

Building on that proposed rule, CMS released another proposal to strengthen prior authorization protections for patients, requiring: a granted prior authorization approval remain valid for an enrollee's entire course of treatment; Medicare Advantage plans to annually review utilization management policies; and coverage determinations to be reviewed by professionals with relevant expertise.

"Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health," said Resneck. "To protect patient-centered care for the 28 million older American that rely on Medicare Advantage, physicians urge CMS to finalize the proposed policy changes and strengthen its prior authorization reform effort by extending its proposals to prescription drugs. We stand ready to continue our work with federal officials to remove obstacles and burdens that interfere with patient care."

Amanda Norris is the Associate Content Manager of Finance, Payer, Revenue Cycle, and Strategy for HealthLeaders.


KEY TAKEAWAYS

More than one hundred medical associations sent a letter to CMS regarding prior authorization reform.

One key ask is for CMS to establish and implement an oversight plan that will hold plans accountable for noncompliance.

More than nine in 10 physicians reported care delays while waiting for health insurers to authorize necessary care.


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