CMS' Medicare Advantage and Part D rule went into effect on January 1.
Will 2024 be the year providers get a handle on prior authorization struggles? With the Medicare Advantage and Part D rule going into effect on January 1, it’s too soon to tell.
The rule, issued by the Centers for Medicare & Medicaid Services (CMS), requires Medicare Advantage plans to review prior authorization policies each year, with the policies remaining in place for as long as the patient needs a service.
Revenue cycle leaders continue to struggle with prior authorization and denials management. With most Medicare Advantage enrollees having plans that require prior authorization for services, the issue is further exacerbated.
Some organizations have tried to solve their prior authorization problems by investing in rev tech solutions. Without a solid digital expansion strategy, organizations can end up with more issues.
In a previous HealthLeaders story, Shanda Richards, revenue cycle director of Central Peninsula Hospital in Alaska, emphasized this while acknowledging the sense of urgency to find a solution.
“We’re in a crisis. We’re delaying care because we can’t get prior authorization, so therefore we have to get something in place,” she said.
Prior authorization is the tip of the iceberg when it comes to organization’s issues with Medicare Advantage. Providers have long been vocal in their frustration with low reimbursement rates and frequent claim denials.
With many health systems struggling financially, it would be unsustainable to keep going back and forth, and many have begun terminating their Medicare Advantage contracts.
“A program intended to promote seamless and higher quality care has instead become a fragmented patchwork of delays, denials, and frustrations,” Steve Gordon, president and CEO of St. Charles Health System, said in a press release. The health system terminated its Medicare Advantage contract in 2023.
“The sicker you are, the more hurdles you and your care teams face.”
Jasmyne Ray is the revenue cycle editor at HealthLeaders.
KEY TAKEAWAYS
The rule requires Medicare Advantage plans to review prior authorization policies each year and remain in place for as long as a patient needs a service.
Health systems that are struggling financially are stretched thin thanks to low reimbursement rates and high number of claim denials, leading some to consider terminating their Medicare Advantage contracts.