MMA Signs on to Letter Urging Prior Auth Reforms by CMS

February 16, 2023

The MMA along with the AMA and 117 other medical societies sent a letter in support of meaningful prior authorization reforms to the Centers for Medicare & Medicaid Services (CMS) on February 13. 

The letter to Administrator Chiquita Brooks-LaSure urged CMS to finalize proposed prior authorization reforms that target the inappropriate use of prior authorization requirements by Medicare Advantage plans to delay, deny and disrupt the provision of medically necessary care to patients.  

Reforms proposed by CMS need to be implemented amid mounting evidence that Medicare Advantage plans are delaying or even preventing Medicare beneficiaries from getting optimal care.  

• The most recent AMA survey found more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care. More than four in five physicians (82%) said patients abandon treatment due to prior authorization struggles with health insurers, and more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.  

• An investigation by the inspector general’s office of the U.S. Health and Human Services Department found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments, in some cases ignoring prior authorizations or other documentation necessary to support the payment.  

• A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about 6% of the 35 million requests submitted in 2021. While about 11% of denials were appealed, the vast majority (82%) of appealed denials were fully or partially overturned, raising serious concerns about the appropriateness of many of the initial denials. 

“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” said AMA President Jack Resneck Jr, MD. “To protect patient-centered care for the 28 million older Americans 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.” 

Many times, commercial insurers will follow the requirements for the Medicare program so these prior authorization rules are very important. “The interferences caused by prior authorization remains a major hassle for physicians throughout Minnesota,” said MMA President Will Nicholson, MD. “Patients deserve to receive the care they need in a timely manner without a third-party interfering.”