CMS Aims to Reduce Prior Authorization Requirements With Medicare Advantage Plans

CMS Aims to Reduce Prior Authorization Requirements With Medicare Advantage Plans

Medicare Advantage (MA) plans will find it harder to require prior authorizations for their coverage under a new final rule from the Centers for Medicare & Medicaid Services (CMS).¹

CMS says the new rule, announced April 5, 2023, is intended to address MA member complaints that prior authorization requirements restrict their access to care.

In response, the rule will:

• Limit the use of coordinated care MA plans’ prior authorization policies to confirming the presence of diagnoses or other medical criteria and/or ensuring that an item or service is medically necessary,

• prohibit coordinated care MA plans from requiring prior authorizations for an active course of treatment for at least 90 days when a patient switches MA plans,

• require all MA plans to establish utilization management committees to ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines, and

• require that prior authorization approvals remain valid “for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.”

“Together, these changes will help ensure enrollees have consistent access to medically necessary care while also maintaining medical management tools that emphasize the important role MA plans play in coordinating medically necessary care,” CMS said.

The rule comes in the wake of a 2022 report from the Office of Inspector General (OIG) of the US Department of Health and Human Services that indicated that some MA plans have been denying prior authorization requests even although the requests met Medicare coverage rules.²

The OIG report also revealed that plans were denying payments to providers for some services that met both Medicare coverage and the MA plan’s own billing rules.

Physicians’ groups hailed the rule. "Family physicians know firsthand how this will help ensure timely access to care while alleviating physicians’ administrative burdens and patients’ care delays,” American Academy of Family Physicians President Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, said in a tweet. Jack Resneck Jr, MD, president of the American Medical Association, said that with the rule, CMS “has taken important steps toward right-sizing the prior authorization process imposed by Medicare Advantage plans on medical services and procedures.”

References

1. 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F). News release. CMS.gov. April 5, 2023. Accessed April 12, 2023.https://go.cms.gov/43pXiZF
2. Some Medicare Advantage organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care. US Department of Health and Human Services Office of Inspector General. April 27, 2022. https://bit.ly/3GBNKRi