Since their inception, Medicare Advantage (MA) plans have been allowed to develop their own proprietary rules as to when patients need prior authorization–permission from their health plan–in order for their care to be covered. Healthcare Dive reports that the Centers for Medicare and Medicaid Services (CMS) has proposed small ways to improve the prior authorization process for Medicare, Medicaid and federally-facilitated state health exchange plans.
Insurers and providers support CMS’ proposed rule to improve the prior authorization process through electronic prior authorization systems. The trade association for health insurers, AHIP, said it was pleased that physicians and hospitals will have an incentive to use electronic prior authorization systems, as using them will affect their quality assessment.
AHIP likely was also pleased that CMS did not try to dictate the scope or nature of prior authorization rules. Until CMS does so, effectively standardizing them, people in MA plans should expect that MA plans’ prior authorization rules will continue to delay their care without offering value, at least in some instances. MA prior authorization rules are often out of sync with standard medical practice, requiring approvals when they should not be needed, can be extremely burdensome on physicians, and can unduly delay critical care.
Today, MA prior authorization rules are not public. They should not be proprietary, but rather should be open to public scrutiny. If they prevent people from getting needed care, the Centers for Medicare and Medicaid Services (CMS) should forbid them; if they help ensure people get the right care, CMS should require them.
Hospitals and other provider groups applaud the streamlining of prior authorization. They also rightly say that the CMS rule does not go far enough, there’s more to be done. The Office for the Inspector General in the Department of Health and Human Services found that MA plans “routinely” inappropriately deny prior authorization requests for care that traditional Medicare covers.
When a Medicare Advantage plan denies a prior authorization request, the patient can appeal. But, few do, believing the process is burdensome and not worth the effort. Consequently, only a tiny portion of people appeal. Of course, that’s what the Medicare Advantage plans are hoping. Not surprisingly, three in four of the appeals are successful for patients, and the denials are overturned.
To get buy-in from insurers, including Medicare Advantage plans. a data exchange provision that more easily allows data sharing among Medicare Advantage plans, physicians and patients will not go into effect for four years!
The Improving Seniors Timely Access to Care Act, which contains importanr prior authorization provisions, passed the House unanimously in September. The Senate has not passed it yet. It would speed up the prior authorization process and standardize more of it.
Here’s more from Just Care:
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