Federally regulated health plans are now required to publicly disclose certain prior authorization data from the previous year on their websites.
But the AMA has found that while many companies appeared to comply with the letter of the rule, a number posted information that was effectively impossible to find or understand. For example, several payers posted disclosures behind provider portals or on webpages that could not be reached by clicking through their public websites, while others omitted required information, reported mathematically impossible figures, or used inconsistent methods to calculate their statistics.
The AMA alerted Centers for Medicare & Medicaid Services (CMS) officials of the widespread problems they uncovered, and CMS officials took the findings seriously.
Specifically, the AMA documented how 15 Medicare Advantage contracts were implementing transparency provisions that are part of the CMS 2024 Interoperability and Prior Authorization rule. The AMA sent a letter to CMS in May (PDF) that documented the problems and recommended corrective actions the government could take. The AMA reiterated the concerns and potential solutions in a follow-up letter (PDF) in June.
“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” said AMA President Willie Underwood III, MD, MSc, MPH.
Yet, he said, that’s exactly what AMA researchers found when they examined how plans were implementing the transparency requirements laid out in CMS’ final rule. The rule applies to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and Qualified Health plan issuers on the federally facilitated Exchanges.
“One plan posted an 832-page list of billing codes without a word of plain English. Others buried required information behind portals. Another published numbers that didn’t add up—and acknowledged that its data should not be relied upon. In other words, thank you for reading this. The information may or may not be true,” Dr. Underwood noted.
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Positive changes
CMS has now provided updated guidance that addresses several of the AMA’s concerns. The eight-page document provides more specific instructions of what is expected to meet prior authorization transparency requirements and contains sample reporting-format templates that include informational graphics and examples of how to convey data in a clear way.
The agency incorporated several of the AMA’s recommendations into the recently released guidance. The guidance:
- Defines what it means for prior authorization information to be publicly accessible. For example, disclosures are not considered publicly accessible if they are available only through password-protected portals.
- Clarifies that public reporting requirements apply to all medical items and services subject to prior authorization, prohibiting payers from excluding entire categories of care from their disclosures.
- Clarifies that prior authorization disclosures must be understandable. Lists of procedure codes without plain-language descriptions don’t satisfy the requirement. CMS recommends a single, comprehensive list organized by uniform service categories, with CPT codes, plain-language descriptions and a machine-readable format.
- Specifies reporting standards to improve the accuracy and reliability of disclosures. Every turnaround-time metric must include a unit of time, and a median turnaround time of less than one day must be reported in hours, not rounded to “0 days.” CMS recommends that payers explain any data quality issues in their reporting.
What else needs to happen
While the new CMS guidance is an important step forward for data transparency and usability, more needs to happen to ensure that patients and physicians have information that is accurate, accessible, understandable and comparable across health plans.
“You shouldn’t have to be a rocket scientist to figure out what the insurance companies are doing,” Dr. Underwood said. “The AMA will continue working with CMS to make sure transparency requirements actually deliver transparency.”
The AMA is urging CMS to address remaining gaps in the federal transparency framework, including:
- Defining prior authorization broadly enough to capture rebranded practices. CMS should define prior authorization based on how the process functions so that it doesn’t matter if the payer calls it “prior authorization,” “precertification” or “advance notice,” or even if the payer delegates the process to a third-party utilization management vendor.
- Making prior authorization information available at the point of enrollment. CMS should link directly from plan pages on Medicare Plan Finder and HealthCare.gov to their prior authorization requirements and performance metrics and should require that states include the same links in Medicaid and CHIP plan-comparison and enrollment tools.
- Standardizing prior authorization reporting. CMS should require standardized templates for prior authorization service lists and performance metrics, rather than just recommending standardizing reporting.
Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.
