Providers Want More from CMS on Prior Authorization Reform After Proposed Changes

Fierce Healthcare | By Robert King
 
Provider groups say new reforms proposed by the Biden administration to streamline prior authorization are a good start. 
 
But much more needs to be done—including creating gold-card programs that let providers skip prior authorization if they have a high volume of requests, they say. 
 
Several provider and payer groups submitted comments on a proposed rule outlining policy changes for Medicare Advantage (MA) and Part D set to take effect in 2024. One of the biggest changes is to clarify when and how MA plans can use prior authorization, a cost containment tool that requires physicians to get insurer approval before doling out certain items and services but has morphed into a major source of administrative burden for providers.
 
“Physician groups point to delays in prior authorization decisions, resubmission of prior authorization, inconsistent payer payment policies … and prior authorizations for routinely approved items and services as some of the most challenging aspects of prior authorization,” wrote the Medical Group Management Association (MGMA) in comments to the proposed rule that were due Monday.
 
If finalized, the Centers for Medicare & Medicaid Services' (CMS’) rule would mandate that a granted prior authorization approval remains valid for the entire course of treatment for a patient in MA. If an MA plan denies coverage for a request, it must rely on a physician or expert that has expertise in the appropriate field of medicine, CMS added.
 
The agency also proposed prior authorization must be limited to only confirming the presence of a diagnosis.
 
But provider groups say this still doesn’t address the problem that any prior authorization process “inherently delays patient care,” MGMA wrote. “CMS must establish guardrails to prevent high volumes of prior authorization requests by MA plans.”
 
One of these strategies could be gold-carding programs that exempt certain clinicians from prior authorization if they have an approval rating over a period of time. This would help ease the number of requests a physician must face.

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