Provider Org Recommends Changes to MA Prior Authorization Rule

The American Academy of Ophthalmology (the Academy) has offered recommendations to CMS on the Medicare Advantage prior authorization proposed rule that may help reduce provider burden and improve patient care.

In a letter emailed to RevCycleIntelligence, the Academy commended the agency for trying to simplify the prior authorization process but noted that certain aspects should be changed.

The organization urged CMS to enforce decision deadlines and public reporting of denial metrics.

The Academy requested that the agency require responses to non-urgent prior authorizations within seven days and responses for urgent prior authorizations within 24 hours. This would align decision timelines with the deadlines in the Improving Seniors’ Timely Access to Care Act.

If payers fail to respond to a request within the set timeframes, providers should be able to treat it as an approval of the prior authorization request, the letter stated.

The Academy also asked CMS to clarify in the final rule that payers must publicly report denial metrics on an individual service basis rather than an aggregate basis, which may not provide the level of detail patients and providers need.

CMS should enforce these rules by developing a voluntary process for providers and patients to report payer non-compliance.

The rule proposed a new measure in the Merit-Based Incentive Payment System (MIPS) requiring MIPS-eligible clinicians to report electronic prior authorization use starting in calendar year (CY) 2026. The Academy urged CMS to withdraw this proposal, as these clinicians may not have adequate EHR technology to track the measure.

The letter also highlighted how implementing application programming interfaces (APIs) may cause significant burdens for small and rural practices due to workflow changes and limited resources.

CMS should expand the rule’s proposals to address other areas of concern, including health equity, step therapy, and digital imaging and communications in medicine (DICOM) standards.

Compared to Medicare fee-for-service (FFS) beneficiaries, Medicare Advantage beneficiaries are more likely to be lower-income, Black or Latino, and dually enrolled in Medicaid. This creates a health equity issue as Medicare FFS rarely requires prior authorization processes, while nearly all Medicare Advantage plans do for at least some services.

The Academy noted how the use of step therapy as a utilization management tool harms patients in a similar way as prior authorization. Thus, the organization urged CMS to extend the electronic prior authorization requirements to Part D prescription drugs and Part B physician-administered drugs.

The Academy also suggested that CMS use similar provisions in the proposed rule to help improve digital image data-sharing between ophthalmologists. Broader support for DICOM standards would help reduce barriers to effective collaboration by providers and promote interoperability, the organization said.

Finally, the Academy opposed CMS’ request for comments on how the prior authorization proposals could be applied under Medicare FFS.

“We ardently oppose prior authorization under Medicare fee-for-service and urge CMS to suspend any existing PA policies on services not mandated by legislation,” the Academy wrote. We believe that PA expansion in fee-for-service has the potential to harm Medicare patients’ access to necessary care and should not move forward without a specific legislative mandate.”

The Academy urged CMS to consider the recommendations before finalizing the rule and increase its oversight of Medicare Advantage plans.

“Unlike the small businesses run by many healthcare providers, we believe that MA organizations have the technological, financial, and practical resources to meet these requirements in 2024,” the letter concluded.