AMA Urges CMS to Finalize Medicare Advantage Prior Authorization Reforms

The American Medical Association (AMA) and 118 other medical organizations have urged CMS to finalize its proposed prior authorization reforms for the Medicare Advantage program.

In a letter to CMS Administrator Chiquita Brooks-LaSure, AMA responded to CMS’ Notice of Proposed Rule Making for Part C & Part D (CMS-4201-P), urging the agency to finalize the proposed reforms that would minimize the inappropriate use of prior authorization requirements by Medicare Advantage plans.

“Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians,” Jack Resneck Jr, MD, president of AMA, said in the press release.

“We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments.”

The proposed rule included provisions that aim to streamline prior authorization requirements by adding continuity of care requirements and reducing disruptions in ongoing care. CMS proposed that when a beneficiary is granted prior authorization approval, it will remain valid for the entire course of treatment.

The agency also proposed that prior authorization policies for coordinated care plans may only be used to confirm the presence of diagnoses or other clinical criteria and ensure that a service is medically necessary. In addition, the rule stated that plans must provide a minimum 90-day transition period when a beneficiary currently undergoing treatment switches to a new Medicare Advantage plan.

The proposals aim to ensure plans are using prior authorization appropriately by requiring plans to establish a utilization management committee to review policies annually and ensure consistency with traditional Medicare’s national and local coverage decisions and guidelines.

AMA urged CMS to finalize these proposals to avoid care delays and disruptions that result from unnecessary prior authorization requirements.

The organization cited past data revealing that physicians and their staff spend an average of two business days per week completing the prior authorization workload for a single physician. Additionally, 88 percent of physicians described their prior authorization burden as high or extremely high, leading to less time with patients.

AMA supported the notion of Medicare Advantage plans implementing gold-carding programs to exempt physicians with high approval rates from prior authorization requirements.

“Our organizations stand ready to work with CMS to develop meaningful guidelines for gold-carding programs that would reduce the volume of PAs to the benefit of all stakeholders, and we encourage CMS to establish a requirement on MA plans to develop such programs,” the letter stated.

AMA referenced a report from the Office of Inspector General (OIG), which found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13 percent of prior authorization requests and 18 percent of payments.

An analysis from the Kaiser Family Foundation also found that Medicare Advantage plans denied two million prior authorization requests in 2021. Around 11 percent of denials were appealed, and 82 percent of those denials were fully or partially overturned. This raises concerns about whether the initial denials were appropriate.

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” Resneck added. “To protect patient-centered care for the 28 million older Americans 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.”