AMA and 118 Other Medical Groups Urge CMS to Finalize Prior Authorization Reforms for Medicare Advantage Program
The American Medical Association (AMA) and 118 other medical organizations have recently urged the Centers for Medicare & Medicaid Services (CMS) to finalize its proposed prior authorization reforms for the Medicare Advantage program. The proposed rule includes provisions that aim to streamline prior authorization requirements by adding continuity of care requirements and reducing disruptions in ongoing care. It would also mandate that a prior authorization approval is valid throughout the entire course of treatment for a Medicare Advantage patient, and an MA plan can only deny coverage if it's backed by a physician or expert with the appropriate medical background.
A recent survey conducted by the AMA found that 93% of doctors reported care delays while waiting for health insurers to authorize necessary care, while 91% said it had a negative impact on patient outcomes, including hospitalization, permanent impairment, or death, according to 34% of the doctors.
The AMA, along with 118 other medical societies, have sent a letter to CMS Administrator Chiquita Brooks-LaSure thanking her and urging the agency to finalize the proposed rules, which “target the inappropriate use of authorization requirements by Medicare Advantage plans to delay, deny and disrupt the provision of medically necessary care to patients,” the release said.
An audit conducted by the Health and Human Services Department's Inspector General revealed that Medicare Advantage plans were not following Medicare coverage regulations when it came to 13% of prior authorization requests and 18% of payments, with some plans disregarding existing authorizations or other necessary documentation.
The physician organizations urged CMS to finalize the proposed rules, which would minimize the inappropriate use of authorization requirements by Medicare Advantage plans to delay, deny and disrupt the provision of medically necessary care to patients. The proposed rule would also ensure that Medicare beneficiaries who select MA plans still have equitable access to traditional Medicare Part A & B benefits.
In response to the OIG report as well as information like the AMA survey, CMS is proposing new rules for MA coverage that would prohibit some forms of prior authorization and would clarify that MA plans must cover basic benefits to the extent they are covered in Original Medicare. The comment period for the proposed rule changes for Medicare Advantage (MA) and Part D ended on February 13th, but CMS will continue to collect responses on prior authorizations until March 13th.
0. “AMA Urges CMS to Finalize Medicare Advantage Prior Authorization Reforms” RevCycleIntelligence.com, 14 Feb. 2023, https://revcycleintelligence.com/news/ama-urges-cms-to-finalize-medicare-advantage-prior-authorization-reforms
1. “Providers want CMS to go further on prior authorization reform” FierceHealthcare, 14 Feb. 2023, https://www.fiercehealthcare.com/providers/providers-want-more-cms-prior-authorization-reform-after-proposed-changes
2. “Medical Societies Unite in Support of Proposed Prior Authorization Reforms – Florida Hospital News and Healthcare …” South Florida Hospital News, 13 Feb. 2023, https://southfloridahospitalnews.com/medical-societies-unite-in-support-of-proposed-prior-authorization-reforms
3. “As CMS tightens vise on Medicare Advantage, providers argue for even more help” McKnight's Long-Term Care News, 15 Feb. 2023, https://www.mcknights.com/news/as-cms-tightens-vise-on-medicare-advantage-providers-argue-for-even-more-help
4. “Prior Authorization Data and Proposed Rule Reflect Need for Stronger Medicare Advantage Rules” Medicare Rights Center, 9 Feb. 2023, https://www.medicarerights.org/medicare-watch/2023/02/09/prior-authorization-data-and-proposed-rule-reflect-need-for-stronger-medicare-advantage-rules
5. “Physician groups voice strong support for prior authorization reforms” Medical Economics, 13 Feb. 2023, https://www.medicaleconomics.com/view/physician-groups-voice-strong-support-for-prior-authorization-reforms