Medicare Advantage Plans Must Rein in Prior Authorizations

AAFP, Others Urge Quick Action by CMS

March 08, 2019 04:55 pm News Staff

The AAFP and nearly 100 other medical professional organizations presented a united front recently in asking CMS Administrator Seema Verma, M.P.H., to provide appropriate direction to Medicare Advantage plans on their use of prior authorizations through the agency's final 2020 call letter.

[prior authorization form concept]

A CMS fact sheet(www.cms.gov) on the draft call letter was released on Jan. 30.

In a Feb. 28 letter(5 page PDF) to Verma, the organizations said CMS should require Medicare Advantage plans to "selectively apply" prior authorization requirements where they are most needed.

The letter noted that prior authorization "can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may, in turn, adversely affect patient health outcomes."

The organizations referred to a 2018 AMA survey of 1,000 practicing physicians in which 91 percent of respondents said prior authorization could delay a patient's access to necessary care.

Additionally, 75 percent of surveyed physicians said prior authorization could lead patients to abandon treatment, and 91 percent said clinical outcomes could be negatively impacted.

Most alarming, the letter continued, was the finding that 28 percent of physicians suggested prior authorization had "led to a serious adverse event … for a patient in their care," including hospitalization, disability, permanent bodily damage and even death.

As further evidence that utilization management requirements can prevent patients from accessing the medical care they need, the letter referenced an HHS Office of Inspector General (OIG) review(oig.hhs.gov) of Medicare Advantage service denials from 2014 to 2016.

The OIG found that each year, 216,000 prior authorization requests that had been initially denied were eventually overturned on appeal, noted the letter.

"These overturned denials represent that the treatments sought were determined to indeed be medically necessary. This figure is particularly concerning because beneficiaries and providers appealed only 1 percent of denials."

The letter also stressed physicians' ongoing concerns with the administrative burden aspect of prior authorization programs and said the "very time-consuming processes used in these programs … divert valuable resources away from direct patient care."

According to the same 2018 survey referenced above, practices completed an average of 31 prior authorization requests per physician per week -- work that consumed nearly 15 hours of combined physician/staff time each week.

Additionally, 88 percent of surveyed physicians reported an increase in their prior authorization burden during the past five years.

Lastly, the organizations registered "serious concerns" about CMS' message to Medicare Advantage plans in the draft call letter that indicated plans would not be prohibited from utilizing step-therapy protocols for physician-administered drugs covered by Medicare Part B this year.

"We find the growing trend toward the use of restrictive and burdensome utilization management tactics by payers concerning and urge CMS to reconsider its stance on this critical patient care issue," said the letter.

Related AAFP News Coverage
Medicare Part D Proposed Rule Triggers AAFP Response
(1/28/2019)

New AAFP Policy Takes Aim at Prior Authorizations
(5/26/2017)

Medical Organization Coalition Calls for Prior Authorization Reform
AAFP Also Drafts Policy on Requirements

(1/26/2017)

Fresh Perspectives blog: Prior Authorization Call Shows Inefficiency, Absurdity of Process
(7/18/2016)