Medicine to Feds: Back Off Prior Authorization Requirements
By Joey Berlin


The Texas Medical Association, American Medical Association, and a host of other medical societies are trying to stop onerous, care-impeding prior authorization (PA) requirements from overrunning Medicare Advantage (MA) plans.

In a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma, the groups says the agency should direct plans to target PA requirements where they are needed most.

“Specifically, CMS should require MA plans to selectively apply PA requirements and provide examples of criteria to be used for such programs, including, for example, ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates,” the letter said.

The letter urges CMS to require MA plans to follow the Consensus Statement on Improving the Prior Authorization Process, issued in January 2018 by the AMA, the American Hospital Association, America’s Health Insurance Plans, and others. That statement identified “opportunities to improve the prior authorization process, with the goals of promoting safe, timely, and affordable access to evidence-based care for patients; enhancing efficiency; and reducing administrative burdens.”

TMA and the others told CMS that PA “can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes.”

The letter notes that in a 2018 AMA survey of 1,000 practicing physicians, 91 percent said prior authorization can delay a patient’s access to necessary care, and the same percentage said PA can have a negative impact on patient outcomes.

Furthermore, a U.S. Department of Health and Human Services Office of the Inspector General review of MA service denials between 2014 and 2016 found more than 116,000 PA requests were denied initially but overturned on appeal, the group’s letter noted.

The letter, sent to Administrator Verma on Feb. 28, also urged CMS to reconsider its recent lifting of the prohibition on step therapy for physician-administered drugs in MA plans, saying medicine is concerned by “the growing trend towards the use of restrictive and burdensome utilization management tactics” by payers.

“In sum, MA plans should target PA requirements where they are needed most and refrain from implementing PA practices that not only increase burden but also jeopardize patient health,” medicine wrote.

Last Updated On

March 07, 2019

Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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