People in Medicare Advantage plans–the private health insurance plans that offer Medicare benefits–contend with multiple challenges to getting care, including restricted networks of doctors, high deductibles and copays, and prior authorization rules. Healthcare Dive reports that the Centers for Medicare and Medicaid Services just issued a rule that would make prior authorization easier for people with Medicaid, people in state health insurance plans and people in the CHIP program beginning January 2023. For some incomprehensible reason, the rule does not apply to people in Medicare Advantage.
As you might expect, the hospitals, doctors and patients generally like the proposed rule. It would standardize and speed up the approval process for the delivery of health care services and medicines, reducing the burden on them. It would means shorter delays in the delivery of care.
But, the providers do not understand why it does not include Medicare Advantage plans. Why shouldn’t they be part of a CMS rule that standardizes data-sharing? They cover millions of people. Not having them included only complicates matters for providers and makes it harder for older adults and people with disabilities enrolled in Medicare Advantage to get care.
What’s problematic about the new rule is that it gives health plans–except for health plans in the state health insurance exchanges–as long as seven days to make a decision about whether to authorize a standard procedure. Even when the procedure is urgent, the insurers have three full days.
Why should health insurers have so much power to delay care and jeopardize people’s health, even in an urgent situation? The American Hospital Association has asked that the timelines be changed to three days in non-urgent situations and 24 hours in urgent cases.
Health insurers, for their part, are not happy with the rule whatsoever. Prior authorization allows them to delay care. At times, it deters people from getting care altogether. Anytime that care is delayed or foregone, the insurers do not spend money and profit.
The new policy also requires insurers to let hospitals and doctors know why they are denying authorization. The insurers complain that the burden is all on them.
The health insurers don’t have much of an argument. They claim “distraction” from containing the pandemic. They also claim that the comment period is too short to enable them to comment appropriately. They say it violates the Administrative Procedures Act.
It’s all hogwash, but that doesn’t mean that the health insurers won’t be able to wield their enormous power to undo the rule. The question is whether the health insurers are more powerful than the doctors, the hospitals and the patients. Most likely yes, since they have more resources.
The rule would force more electronic interoperability among providers and insurers. For all kinds of reasons, the improved ability to exchange data is important.
Here’s more from Just Care:
- Ten ways Medicare Advantage plans differ from traditional Medicare
- Seven reasons commercial insurance cannot meet our health care needs
- Office of Inspector General finds that Medicare Part D plans inappropriately deny drug coverage
- Inappropriate Medicare Advantage care denials appear widespread
- Most people choose traditional Medicare over Medicare Advantage
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