- Senate bill introduced to research impact of AI tools on older Americans
- OIG reports probe Medicare Advantage prior authorization denials for post-acute care
- AMA responds to HHS RFI on the chronic disease of addiction
- CMS releases 2024 Merit-based Incentive Payment System public use data, discontinues publishing Quality Payment Program Experience Report
- Op-eds nationwide highlight urgent need for Medicare physician payment reform
- More articles in this issue
Senate bill introduced to research impact of AI tools on older Americans
The bipartisan Aging with Artificial Intelligence Act was introduced in the Senate by Sens. Mark Kelly (D-AZ), Rick Scott (R-FL) and Roger Marshall, MD (R-KS). The legislation, which was worked on in partnership with AMA expertise and guidance, would direct federal research on how AI tools, including chatbots and voice assistants, are impacting older Americans.
AMA CEO John Whyte, MD, MPH, was quoted in the press release praising the introduction of the legislation, saying, "AI holds tremendous potential to help older adults stay connected, informed, and independent, but we must better understand its impact before widespread adoption outpaces evidence. The Aging with Artificial Intelligence Act is a smart, forward-looking step that will help ensure these technologies are safe, effective, and centered on the needs of older Americans. The AMA applauds Sens. Mark Kelly, Rick Scott, and Roger Marshall for their leadership."
The legislation is also supported by the American Psychological Association, AARP, the National Council on Aging, the Mental Health AI Policy Project, and the Alliance for Secure AI. The AMA looks forward to working with the sponsors of the legislation and the Senate to see this legislation signed into law.
OIG reports probe Medicare Advantage prior authorization denials for post-acute care
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released two reports detailing serious issues with Medicare Advantage (MA) plans’ prior authorization (PA) denials for post-acute care. These investigations reinforce longstanding AMA concerns (including those detailed in a May 2024 letter [PDF]) about inappropriate MA PA denials for post-acute care admissions and the need for greater oversight of plans’ utilization management practices. PA-related treatment barriers are particularly devastating for vulnerable patients seeking post-acute care, as delaying services such as rehabilitation and physical therapy can negatively impact long-term clinical and functional status.
The first report (PDF) studied PAs for admissions to long-term care hospitals (LTCH) and inpatient rehabilitation facilities (IRF) in June 2024 and found that:
- The three largest MA organizations by enrollment (CVS Health, Humana, and UnitedHealthcare) denied care at higher rates than most other MA plans.
- These three plans denied over 70% and 50% of PAs for LTCH and IRF admissions, respectively.
- MA plans overturned 36% and 43% of LTCH and IRF PA denials on appeal, respectively.
- Overturn rates varied considerably, with some plans, such as CVS Health, overturning over 80% of IRF PA denials.
In a companion report (PDF), the OIG evaluated MA plans’ PA decisions for skilled nursing facility (SNF) admissions in June 2024 and found that:
- The collective denial rate across plans was 12%.
- While only 18% of denials were appealed, MA plans overturned 95% of these denials—suggesting that MA plans regularly withhold medically necessary post-acute care.
Both reports note the outsized role that naviHealth, a utilization management vendor, played in MA plans’ denials of LTCH, IRF, and SNF care.
In both reports, the OIG recommended that the Centers for Medicare & Medicaid Services (CMS) evaluate the reasons for variation in denial and overturn rates between MA plans and take appropriate action. Importantly, the OIG also recommended that CMS collect service-level data regarding MA plans’ PA programs, which reflects ongoing AMA advocacy (including a May 2026 letter [PDF]) calling for increased granularity in plans’ publicly reported PA metrics. To learn more about the AMA’s PA reform efforts, visit FixPriorAuth.org.
AMA responds to HHS RFI on the chronic disease of addiction
The AMA recently submitted comments (PDF) to HHS in response to a Request for Information focused on substance research, policy, and strategies to improve the prevention, treatment, and recovery of the chronic disease of addiction and mental illness.
The AMA’s response highlighted support for the fact that national overdose rates have decreased, stating that an essential part of the solution to maintain—and perhaps increase—the positive trends in reduced death is to—at a minimum—maintain funding to help support innovative and long-standing evidence-based care for substance use disorders (SUD), mental illness, and co-occurring mental and chronic disease of addiction. The AMA also strongly encouraged HHS and its component agencies to continue supporting efforts to reduce the transmission of blood-borne infectious diseases, including medications for opioid use disorder (MOUD), naloxone, and sterile needle and syringe exchange services.
The letter also emphasized that increasing enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) will save lives. The 2025 MHPAEA Report to Congress from the Department of Labor, HHS, and the Department of the Treasury (PDF) demonstrates that payers continue to routinely fail to comply with MHPAEA’s basic requirement to treat mental health and SUD benefits no more restrictively than medical and surgical benefits. The AMA urged the Administration to use its authority to enforce MHPAEA as strongly as possible—and set clear expectations for payers that parity violations are wholly unacceptable.
Another recommendation from the letter focused on increasing access to MOUD as it has demonstrated success in treating opioid use disorder, sustaining recovery, and preventing death. The AMA commented that increasing access, however, will require continued and increased efforts to remove prior authorization for MOUD in Medicare Part D and Medicaid. The AMA voiced support for the Administration’s efforts to remove prior authorization and other harmful payer policies that delay and deny care; however, the letter highlighted that prior authorization for MOUD remains an ongoing barrier to care.
CMS releases 2024 Merit-based Incentive Payment System public use data, discontinues publishing Quality Payment Program Experience Report
CMS recently published the 2024 Quality Payment Program (QPP) Public Use File (PUF). However, to the dismay of the AMA, CMS indicated it had discontinued publication of the QPP Experience Report, which is the companion report to the PUF and the main source of information released to the public regarding Merit-based Incentive Payment System (MIPS) and Alternative Payment System (APM) performance. The QPP Experience Report is also frequently utilized by the AMA and physician specialty societies to educate their members and inform policy discussion, as well as being the sole source of information measure stewards and developers receive from CMS regarding measure adoption and performance. Therefore, the AMA recently sent a letter (PDF) to CMS urging them to release the report and prioritize the publication of more meaningful and accessible annual QPP reports.
Based on the AMA’s analysis of the 2024 QPP PUF, 87% of the clinicians received a score higher than 75 in MIPS, which qualified them for a payment increase, while 7.6% received a score below 75 and qualified for a penalty, with the remaining 5.1% receiving a neutral score which will result in no adjustment in payment. 1.4% received the maximum penalty of -9%, while 6.4% received the maximum bonus of 1.05%. Once again, smaller practices were more likely to receive penalties, particularly the maximum penalty, than larger practices- typically due to non-reporting/submitting MIPS data to CMS.
This further highlights the need for Congress to support HR 8622, Medicare Physician Data-Driven Performance Payment System (DPPS) Act of 2026, which mandates that CMS fulfills its statutory obligations under MACRA to share more frequent data so physicians can leverage this data to implement changes that would improve patient care and use resources more efficiently. Failure by CMS to provide MIPS physicians with three quarters worth of data during the performance year results in physicians receiving the highest possible payment update.
Op-eds nationwide highlight urgent need for Medicare physician payment reform
Continuing the momentum for Medicare physician payment reform, physician leaders and key opinion leaders recently published multiple op-eds in publications nationwide. These articles underscore the urgent need for Congress to address and implement meaningful physician payment reform.
- Washington is undermining America’s doctors (RealClear Health)
- Landrieu, Livingston: Time to fix Medicare payments (State Affairs)
- Prior authorization delaying healthcare longer than Texans can—or should—wait (San Antonio Express News)
- Michigan’s emergency rooms are feeling the strain of a broken Medicare system (Bridge Michigan)
- Strengthening healthcare access (Norfolk Daily News)
To lend your voice to the growing list of physicians across the country urging Congress to fix the flawed Medicare physician payment system, visit the Fix Medicare Now site and take action today.
