How CMS Can Standardize Prior Authorization Using MA Star Ratings

In its comments on the CMS advance notice for Medicare Advantage (MA) and Part D changes, the Medical Group Management Association (MGMA) urged CMS to pursue greater transparency in Medicare Advantage plans’ prior authorization requirements, increase the automation of the prior authorization process, and leverage Medicare Advantage (MA) star ratings to alleviate prior authorization burdens.

CMS recently released its advance notice for Medicare Advantage and Part D changes, as part of its plan for contract year 2021 through 2022. The advance notice includes some changes to Medicare Advantage star ratings, intended to lower drug pricing and improve quality of care. These changes included reporting on generic and biosimilar utilization information and placing more weight on patient experience.

Shortly afterward, MGMA noted in its letter, HHS also released its strategy for decreasing the burden that EHRs place on physicians.

In referring to the HHS strategy, MGMA highlighted the Administration’s goal of decreasing the electronic documentation burden for physicians. The Association then explained how those goals could be usefully applied to physicians in Medicare Advantage to improve the star ratings and quality measures.

“As the Agency develops measures to apply to the star rating program, the goal should be to reduce the administrative burden for physician practices associated with meeting MA plan prior authorization requirements and improve the care that practices deliver to Medicare beneficiaries,” MGMA asserted.

In support of these aims, MGMA offered eight recommendations for how CMS can improve MA standards to reduce physicians’ administrative burdens.

First, MGMA supported updating the operating rules that apply timeframe constraints on prior authorization processes. For example, the rule, as established by the Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange (CAQH CORE), says that MA health plans have two business days to review and respond to a prior authorization request.

Second, MGMA would have CMS require MA plans to meet the requirements for a CORE Certification Seal, indicating that they abide by the CAQH CORE prior authorization operating rules. MGMA argued that doing so could move the industry toward standardizing prior authorization procedures, since one stage of the CAQH CORE operating rules checks whether plans have standardized their processes.

Third, the letter promoted greater transparency from MA plans regarding products and services that are subject to prior authorization and what their processes are. The association suggested having MA plans send in a list of their products and services for which they require prior authorization. Plans should also send in a template of their prior authorization process, MGMA said.

MGMA argued that this would streamline the process for clinicians, making it less of a burden, and that the transparency will allow developers to create tools that are better suited to these processes.

MA plans could also have a “gold card” program that would diminish prior authorization burdens for physicians who have proven their compliance with the plan’s rules. The threshold would be high — the provider must achieve a 90 percent compliance rate during a semiannual analysis. But the strategy rewards and incentivizes compliance and ultimately decreases providers’ administrative burden.

MA plans could also reward providers who take on risk in value-based reimbursement models. These providers are already aligned with the cost-effective, high quality objectives of value-based care. And since these models are so worthwhile, it would be beneficial to incentivize providers to enter into such contracts.

Two of MGMA’s recommendations involve MA plans incentivizing providers to adopt certain electronic transaction models. X12 278 for prior authorization transactions and X12 275 for electronic attachments result in greater savings and effectiveness for providers but they have seen low uptake among providers.

Lastly, MGMA argued that clinicians should not have to seek prior authorization for surgical operations, invasive procedures, or the tools for these clinical activities under Medicare Advantage plans, MGMA said. The prior authorization process can impede patients from obtaining timely care in these situations.

“In conclusion, MGMA supports the objective of leveraging the Star Ratings Program to help address some of the prior authorization challenges currently facing physician practices,” the letter stated. 

“However, it will be critical for CMS to select measures that serve to significantly enhance automation between practices and MA plans regarding prior authorization, decrease practice administrative burden and cost, and result in demonstrable improvements to the patient care delivery process.”

This letter from MGMA is only the latest example of physician groups’ frustration with payers regarding prior authorization and EHRs. 

In May 2019, an American Medical Association (AMA) survey found that 69 percent of physicians participating in the survey said that it was somewhat or extremely difficult to communicate with payers regarding prior authorization.

As CMS receives feedback on its MA and Part D alterations, the agency will have to deftly navigate these complex payer-provider tensions if it wants to nudge the industry toward standardized prior authorization procedures.