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Physician groups voice strong support for prior authorization reforms


CMS collecting comments on elements of Medicare Advantage, Part D

Physician groups are lining up to support reforms to the prior authorization (PA) process for medical treatments.

The American Medical Association (AMA) and 118 organizations joined on a letter outlining PA recommendations, sent to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure. CMS is considering rule changes to the prior authorization process and elements of Medicare Advantage (MA) plans.

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” AMA President Jack Resneck Jr., MD, said in a news release. “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.”

A burden on doctors and patients

Prior authorizations are a paperwork burden that takes up physicians’ and staff time while delaying care for patients, according to 93% of doctors surveyed by AMA. Those results showed 91% of physicians see PA having a negative effect on patients’ clinical outcomes – and serious ones, including hospitalization, permanent impairment, or death, according to 34% of the doctors.

Meanwhile, last year the Office of the Inspector General found 13% of PA requests denied by Medicare Advantage (MA) plans met Medicare coverage rules, while 18% of payment request denials met MA and Medicare billing rules, according to AMA.

“We applaud CMS’ proposed policy responses to the findings of the OIG’s report and to ongoing stakeholder concerns and urge CMS to finalize these policies to help protect beneficiaries’ access to medically necessary care,” the AMA letter said.

Improving the process

Among the health groups’ recommendations:

  • MA plans must use PA to confirm diagnoses or medical criteria and ensure medical necessity of services, not to delay or discourage care.
  • MA beneficiaries must have equal access to items and services as those using traditional Medicare. If applicable coverage rules don’t exist, insurers must use and make public the treatment guidelines or clinical literature for coverage criteria.
  • MA insurers must for a utilization management committee to review clinical coverage criteria.
  • MA insurance plans cannot deny care based on a particular provider type or setting unless they do not meet criteria for medical necessity.
  • PA approvals must remain valid for the duration of treatments and once approved, cannot be denied retroactively for lack of medical necessity.
  • Physicians with high PA approval rates should have a “gold carding” program that exempts them from PA requirements.
  • Medicare Part D plans should implement a real time prescription drug benefit standard that allows physicians to check on PA requirements and drug formulary status at the point of prescription.
  • Extend proposed clinical validity and transparency of coverage criteria policies to prescription drugs.

“We urge CMS to finalize these important changes for MA and Part D plans and look forward to continuing to work with you to reduce the burden of PA as it relates to all care in all health insurance markets,” the letter said.

Comments continue

CMS last year published three proposed rule changes that would affect different elements of prior authorizations and Medicare Advantage plans. The comment period ended Feb. 13 for proposal on some elements of MA and Medicare Part D, but CMS will collect responses on prior authorizations through March 13. The comment period for health care attachments involving charts, x-rays, and provider notes for physician referrals will last until March 22.

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