What’s the news: With the first reporting deadline come and gone for Medicare Advantage plans to adhere to a federal rule that aims to bring transparency, accountability and public oversight to prior authorization practices, the AMA is urging the Centers for Medicare & Medicaid Services (CMS) to make changes to strengthen how the rule is implemented and how the reporting framework can be expanded.
In a letter to CMS Administrator Mehmet C. Oz, MD, AMA Executive Vice President and CEO John Whyte, MD, MPH, said that the AMA strongly supports CMS’ goals that the 2024 Interoperability and Prior Authorization final rule advances, but that there is a “need for targeted implementation refinements so that the rule can fully deliver on the transparency, consistency and oversight goals CMS established.”
“The rule reflects a clear recognition by CMS that [prior authorization] transparency is not merely an administrative reporting exercise; it is an essential protection for patients, a tool for holding payers accountable and a prerequisite for evaluating whether [prior authorization] is being used appropriately. As with any major federal transparency initiative, however, the first year of implementation has revealed areas where additional standards would help ensure the rule achieves CMS’ full intent,” Dr. Whyte wrote.
Based on an AMA evaluation, the 14-page letter identifies areas for improvement and offers suggestions on what CMS can do to strengthen the rule’s implementation and reporting framework.
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Why it’s important: The AMA reviewed disclosures for 15 Medicare Advantage contracts in Miami-Dade, County, Florida, after the March 31 deadline for reporting requirements and discovered “significant deficiencies in the accessibility, completeness, format and underlying methodology of the disclosures,” according to the letter the AMA sent to Dr. Oz.
The evaluation looked at compliance with public posting requirements and reporting deadlines; the accuracy, completeness and methodological consistency of reported data; and the accessibility and interpretability of public disclosures. The AMA concluded that:
- Required prior authorization data is posted in locations that beneficiaries and physicians and other providers cannot reasonably find.
- Reported metrics contain errors, omissions of required data and inaccuracies.
- Service lists varied widely in format, organization and granularity, making prior authorization requirements difficult to interpret and compare across plans.
- Plans used different methodologies and reporting levels than required under the 2024 Interoperability and Prior Authorization final rule, obscuring contractwide variation and creating the appearance of more favorable prior authorization practices and outcomes.
“These findings do not dimmish the importance of the [rule]. Rather, they underscore the need for targeted implementation refinements so that the rule can fully deliver” on CMS’ goals, the letter said.
Based on the findings, the AMA offered up detailed ideas for how CMS can make improvements. The AMA suggested changes that would:
- Link to prior authorization metrics and requirements from each plan’s page in Medicare Plan Finder.
- Establish standards governing the location and discoverability of prior authorization disclosures.
- Establish standards for the quality, consistency and scope of reported data.
- Standardize the format and content of prior authorization lists.
- Create a prior authorization comparison tool within Medicare Plan Finder.
- Establish oversight and enforcement procedures for prior authorization reporting compliance.
The AMA also made recommendations on how CMS could strengthen and expand the rule’s reporting framework by requiring:
- Plan-level reporting of prior authorization metrics and service lists.
- Service-level reporting of prior authorization metrics.
- Plans to publicly report the most common reasons for denials.
The rule “represents an important step toward greater transparency, but the AMA’s review shows that transparency requirements only achieve their purpose when the required information is accessible, comparable, accurate and usable in real-world decision making,” Dr. Whyte wrote. “Strengthening implementation of the rule would better equip beneficiaries to evaluate coverage options, help physicians identify [prior authorization] requirements before care is delayed and give CMS more reliable information to oversee [Medicare Advantage] organizations and identify problematic [prior authorization] practices.”
Learn more: The House Ways and Means Health Subcommittee last week passed the Improving Seniors’ Timely Access to Care Act. The measure would, among other things, simplify and accelerate prior authorization decisions and promote transparency. In a statement, the AMA commended the Senate subcommittee for its action to advance the bill.
“This bipartisan legislation would eliminate unnecessary administrative red tape in Medicare Advantage to ensure that critical, lifesaving care is no longer delayed by an overused prior authorization process,” said AMA CEO John Whyte, MD, MPH. He went on to thank the bill’s sponsors and the subcommitee leadership “for prioritizing patient needs over paperwork and look forward to working with lawmakers to enact this vital reform.”
Discover what the most recent AMA prior authorization survey (PDF) of physicians discovered about how many patients abandon treatment because of prior authorization and the care delays associated with the practice.
Visit FixPriorAuth.org to see how patients, physicians and health professionals around the country are negatively affected by prior authorization burdens and to share your story.
