The impetus to fix the prior authorization is being generated following a report from the Inspector General’s Department of Health and Human Services (OIG) showing that Medicare Advantage plans delayed and denied patients access to medically necessary treatment. They also denied payments to doctors and other health care professionals for services that complied with coverage and billing rules.
The OIG found that 13% of pre-authorization applications denied by Medicare Advantage plans met traditional Medicare clinical coverage rules. And of the study sample claims for denial of payment, 18% complied with Medicare coverage rules and Medicare Advantage plan billing rules.
The OIG recommended that the Centers for Medicare and Medicaid Services (CMS):
Issue new guidelines on the appropriate use of Medicare Advantage clinical criteria in medical needs reviews. Update your audit protocols to address the issues identified in this report, such as the use of the clinical criteria in Medicare Advantage plans. Direct Medicare Advantage plans to take action to identify and address vulnerabilities that can lead to manual review errors and system errors.
According to the OIG report (PDF), “CMS agreed with all three recommendations.”
Why it’s important: WADA President-elect Jack Resneck Jr., MD, told The New York Times that denials of Medicare Advantage plans have become commonplace and that prior authorization “has spread far beyond its original purpose “.
In a statement, WADA President Gerald E. Harmon, MD, added that the OIG report “found information that reflects the experiences of physicians. He noted that pre-licensed physician surveys (PDF) of the WADA “have consistently found that excessive authorization checks required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied or interrupted.”
In addition to the CMS adoption of the OIG recommendations, Dr. Harmon said “more needs to be done to reform the prior authorization.” He cited WADA’s support for the “Improving Timely Access to Care for the Elderly” Act (HR 3173; p. 3018), which would require Medicare Advantage plans to streamline and standardize prior authorization processes and improve the transparency of requirements “.
The bill has garnered the bipartisan support of more than 300 members of Congress in the House and Senate. Learn more about how legislation would reduce pre-authorization charges (PDFs) and how doctors can urge their senators and representatives to come together to support them.
“Now is the time,” Dr. Harmon said, “for federal lawmakers to act to improve and streamline the prior authorization process so that patients have timely access to quality, evidence-based health care. they need “.
On another front, the WADA welcomed the Biden administration’s rule issued earlier this month that reinforces the adequacy of the Medicare Advantage network. As a rule, CMS will approve an application for a new or expanded Medicare Advantage contract only after applicants have demonstrated a sufficient network of contracted physicians to care for enrollees.
The WADA has written (PDF) in support of the proposal, saying that these enhanced Medicare Advantage (MA) plans would allow patients to access the services they need.
“Sunlight is said to be the best disinfectant, and that’s what this rule is about. It will bring sunlight into the decision-making process so that patients know that the MA plan they are enrolled in has a proper network, “said Dr. Harmon. “Obviously, this information is needed at the beginning of the process. Discovering that you don’t have access to the care you need at a time of illness adds a challenging layer to a time when it already is. We warmly welcome this patient-friendly CMS move. ”
Learn more: Earlier this spring, WADA submitted comments (PDF) in response to the request for information on electronic prior authorization from the Office of the National Coordinator of Health Information Technology (ONC). ONC and CMS are considering policies to address widespread issues with prior authorization.
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