The leading medical societies, including the American Medical Association (AMA) and 118 others, have come together to support prior authorization reforms proposed for Medicare Advantage and the Medicare prescription drug benefit.
The prior authorization reforms were proposed in the Centers for Medicare & Medicaid Services’ (CMS) Notice of Proposed Rule Making for Part C & Part D. The proposed rule targets the delays or disruptions in medically necessary care that have been reported due to prior authorization requirements. The organizations showed their support in a letter sent to CMS Administrator Chiquita Brooks-LaSure.
93% of Physicians Experience Care Delays Due to Prior Authorization Rules
The letter referred to recent AMA survey data that showed that “93 percent of physicians report care delays or disruptions associated with prior authorization” and “34 percent of physicians report that prior authorization has led to a serious adverse event (e.g., hospitalization, permanent impairment, or even death) for a patient in their care and that 91 percent of physicians see prior authorization as having a negative effect on their patients’ clinical outcomes.”
Additionally, the Office of Inspector General 2022 report found that “13 percent of prior authorization requests denied by Medicare Advantage (MA) plans met Medicare coverage rules, and 18 percent of payment request denials met Medicare and MA billing rules.”
In an AMA press release, AMA President Jack Resneck Jr, M.D. said, “Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health.”
Dr. Resneck continued, “To protect patient-centered care for the 28 million older American that rely on Medicare Advantage, physicians urge CMS to finalize the proposed policy changes and strengthen its prior authorization reform effort by extending its proposals to prescription drugs. We stand ready to continue our work with federal officials to remove obstacles and burdens that interfere with patient care.”
The organizations used the letter to express support for a number of provisions to “protect access to care.” Notably, they showed support for those provisions that improved the “coverage criteria used in medical necessity determinations.” Additionally, they showed support for policy proposals that would protect patients from “care interruptions, treatment delays, and unanticipated medical costs.”
The organizations expressed support for gold-carding programs. These programs would “exempt physicians with high approval rates from prior authorization requirements.”
The organizations additionally showed support for automation efforts. In the letter, they supported the proposed rule’s requirement that “Part D plans implement the National Council for Prescription Drug Programs Real Time Prescription Benefit standard.” Doing so would allow “physicians to check prior authorization requirements and drug formulary status at the point of prescribing in EHRs and support informed conversations with patients about therapy costs.”
