A while back now, the House of Representatives passed the Improving Seniors Timely Access to Care Act, designed to address problems individuals and hospitals face because Medicare Advantage plans impose burdensome prior authorization requirements, often with little if any medical justification. Unfortunately, it’s not clear that the bill will do anything to improve Medicare Advantage insurer behavior and ensure that prior authorization demands are evidence-based and resolved speedily.
As it is, no matter the legal requirements, Medicare Advantage insurers can and often do violate many, if not most, regulations with near impunity. CMS does not have the power to penalize them for so doing or the resources to adequately oversee them. So, any bill without serious penalties for non-compliance is more sizzle than anything meaningful. This bill lacks meaningful penalties.
(The problems with prior authorization are far larger than Medicare Advantage. They extend to everyone with private health insurance. Only people in Traditional Medicare can know that if their treating physician believes a procedure is medically necessary, Medicare will cover it; there are no prior authorization requirements. This NY Times Video makes the case against prior authorization.)
The Improving Seniors Timely Access to Care Act lacks teeth. But, beyond its failure to require appropriate punishments on Medicare Advantage plans that impose burdensome and non-medically justified prior authorization (PA) requirements or needlessly delay their PA decisions, the bill does not call for some basic fixes to the broken prior authorization system.
We need consistent criteria for Medicare Advantage PA requirements. Proprietary PA lists and policies, which are different for each plan, prevent patients from meaningful Medicare Advantage plan comparisons and impose huge costs on physicians. Physicians need to know what services or procedures will require a PA without having to research which plan the patient has and what that plan’s PA list includes or does not include. Today, medical practices are at a loss to know what they will need to do to ensure their patients in different MA plans get the care they need.
PA requirements must be evidence-based, relating to medical necessity; CMS must ensure they are not arbitrary, preventing coverage of medically necessary services. CMS has Payment Advisory Councils across the country, with representation from all specialties, for determining medical necessity of every procedure. It would be easy to add review of PAs to this system to ensure their medical necessity, and then standardize them across plans.
This bill should help ensure that MA plans cover the care they are required to cover and prevent them from inappropriately denying care through the use of non-evidence based PA requirements. Reducing the turnaround time for PA decisions without meaningful penalty is not nearly enough given what we know to be harmful, arbitrary, overly burdensome and unpredictable PA rules in some, if not many, MA plans.
The goal: Evidence-based prior authorization requirements, as well as the consistent coverage of Medicare benefits among MA plans and between MA plans and TM. Ideally, insurers should all rely on the same set of PA requirements that have been determined to be evidence-based. If PA requirements are not evidence-based, the insurers are violating Medicare rules that they are required to abide by—covering all Medicare-covered services. And, if the MA plans don’t all abide by the same requirements, how is someone to make a meaningful distinction between an MA plan that has an excessive number of PA requirements (evidence-based or not) and an MA plan that has a reasonable number that are evidence-based?
Issues in the bill still in need of addressing:
- Proprietary PA lists do not allow for meaningful comparison among MA plans by individuals or meaningful oversight of MA plans by CMS. CMS should develop the list of evidence-based PA criteria and not allow for variation.
- “Real time” PA decisions should mean nothing short of immediate electronic approval if the PA request meets criteria. As a goal, the “real time” requirement has no teeth.
- The bill allows plans to require all kinds of arguably non-evidence-based documentation before it adjudicates the PA request, opening up the process to gaming by the insurers to the potential detriment of the health of enrollees. At the very least, insurers should be required to publicly disclose and justify all required PA documentation, which should be subject to CMS review and approval, as with MA marketing materials.
- The bill allows health plans to take as long as they need in approving a PA due to “extenuating circumstances.” How long is that exactly? And what is the penalty for noncompliance? If no penalty, no benefit to the rule.
- Instead of requiring insurers to disclose proactively the services for which they require PA, the bill requires insurers to do so retroactively. The bill should require proactive submission of the list of services the insurer intends to apply a PA onto for the coming year and it should need CMS’ approval if those are different from the previous year. If an MA insurer finds a need to add additional PAs mid-year, that should require CMS approval. Moreover, the bill should forbid plans from using PA on services it has not disclosed to CMS and automatically should penalize plans for so doing.
- People should be able to review the list of an MA plan’s PA requirements when they are shopping among MA plans. That list should be publicly posted for everyone, not just sent to providers entering into a new contract.
- Insurers should be required to let patients and providers know the reason they deny a PA. People should not have to request it.
- Insurers should be permitted to use AI to expedite approvals but should not be allowed to use AI to deny care.
Here’s more from Just Care:
- Medicare Advantage plans denied two million prior authorization requests in 2021
- How prior authorization requirements in Medicare Advantage could threaten your health
- 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
- New study finds you can’t meaningfully choose among Medicare Advantage plans
- Five big Medicare access to care issues put vulnerable people at serious risk
Leave a Reply