Advocacy Update

Feb. 24, 2023: Advocacy Update spotlight on prior authorization in Medicare Advantage


After years of AMA advocacy, the Centers for Medicare & Medicaid Services (CMS) issued several Notices of Proposed Rulemaking (NPRM) addressing various aspects of prior authorization. In response to the Part C & Part D NPRM, the AMA submitted comments to CMS, and the AMA also joined with more than 120 physician organizations in a sign-on letter to CMS supporting the proposed reforms of prior authorization in Medicare Advantage and the Medicare prescription drug benefit.  

AMA comments: CMS’ prior authorization reforms are a significant step forward

In its comments, the AMA applauded CMS for acknowledging concerns surrounding prior authorization by proposing meaningful reforms that align with and go beyond the AMA’s Prior Authorization Principles and Consensus Statement (PDF).  

The NPRM proposals are a significant step to rightsizing prior authorization. If CMS finalizes the prior authorization policies in the Part C & Part D NPRM, it will increase access to medically necessary care for MA beneficiaries across the country. In recently submitted comments (PDF) in response to the NPRM, the AMA urged CMS to finalize various proposed provisions that would improve the coverage criteria used in medical necessity determinations, ensure a clinically sound foundation for prior authorization programs and protect access to care. The AMA developed a Recovery Plan for America’s Physicians to address pivotal issues, such as prior authorization, that hinder physicians from providing optimal care and to seek fundamental changes to create a health system that better supports patients and the physicians who care for them. The NPRM directly addresses many of the issues that the Recovery Plan aims to address. In addition, the AMA’s comments covered several topics, including ensuring timely access to care, network adequacy, protecting beneficiaries, strengthening quality, advancing health equity, improving drug affordability and access, and e-prescribing and health IT standards. 

Physician organizations agree, urge CMS to finalize proposed prior authorization reforms

Similarly, the AMA and nearly 120 physician organizations sent a letter (PDF) to CMS Administrator Chiquita Brooks-LaSure thanking her and urging the agency to finalize proposed 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. 

“Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians,” said AMA President Jack Resneck Jr., MD. “We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments.” 

Among other things, CMS should finalize provisions requiring that Medicare Advantage plans: 

  • Only use prior authorization to confirm diagnoses or other medical criteria and ensure the medical necessity of services. That is, prior authorization is not a tool to be used to delay or discourage care. 
  • Give their beneficiaries access to the same items and services as they would under traditional Medicare. When no applicable coverage rule exists under traditional Medicare, plans must use current evidence from widely used treatment guidelines or clinical literature for internal clinical coverage criteria, which must then be made publicly available. 
  • Establish a utilization-management committee to review their clinical coverage criteria and ensure consistency with traditional Medicare guidelines. 
  • Not be allowed to deny care ordered by a contracted physician based on a particular provider type or setting, unless medical necessity criteria are not met. 

For more information, read the full story from Kevin B. O’Reilly, AMA news editor, and view the AMA’s complete comments (PDF).