The American Medical Association (AMA), along with 118 medical societies, have teamed up to support meaningful prior authorization reforms proposed for Medicare Advantage and the Medicare prescription drug benefit.
The Centers for Medicare and Medicaid services (CMS) published a proposed rule in December 2022 that aimed to streamline the prior authorization process. Healthcare groups have long argued that prior authorization creates a burden on providers and could delay critical patient care. Healthcare groups, including the AMA, have urged CMS to make prior authorization easier.
In particular, the AMA and other groups are urging CMS to finalize reforms that target prior authorization in Medicare Advantage plans that delay, deny and disrupt medically necessary care to patients. The healthcare groups collectively sent a letter to CMS Administrator Chiquita Brooks-LaSure about the proposed rule and pushed for the rule to be finalized.
“Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians,” AMA President Jack Resneck Jr., MD, said in a statement. “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.”
According to the AMA, MA plans are facing major challenges with prior authorization and the impact on patients is “alarming.” A whopping 93% of physicians surveyed by the AMA reported delays in care while waiting for health insurers to authorize necessary care. In addition, 82% of physicians said patients tend to abandon treatment due to prior authorization struggles with insurers, and another 34% said prior authorization has led to an adverse event, such as hospitalization, disability, or even death, for a patient in their care.
“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” Resneck said. “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.”
The letter specifically supports reforms related to continuity of care and reliance on approvals, such as approvals remaining valid for the duration of the course of treatment, providing beneficiaries with a 90-day transition period and not allowing MA plans to retroactively deny coverage for a lack of medical necessity. Plus, healthcare groups are asking CMS to finalize efficiency reforms, like allowing physicians to check prior authorization requirements and drug formulary status at the point of prescribing in EHRs and support informed conversations with patients about therapy costs.
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."