The American Medical Association (AMA) and 118 leading medical societies have united in strong support of the meaningful prior authorization reforms proposed for Medicare Advantage and the Medicare prescription drug benefit.
The physician organizations sent a letter to Administrator Chiquita Brooks-LaSure thanking her and urging the Centers for Medicare & Medicaid Services (CMS) to finalize proposed prior authorization reforms that target the inappropriate use of 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.”
Reforms proposed by CMS must be implemented amid mounting evidence that Medicare Advantage plans are delaying or even preventing Medicare beneficiaries from getting optimal care, resulting in alarming effects on patient health.
The most recent AMA survey found more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care. More than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers, and more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.
An investigation by the inspector general’s office of the Health and Human Services Department found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments, in some cases ignoring prior authorizations or other documentation necessary to support the payment.
A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about 6% of the 35 million requests submitted in 2021. While about 11% of denials were appealed, the vast majority (82%) of appealed denials were fully or partially overturned, raising serious concerns about the appropriateness of many of the initial denials.
“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” said Dr. Resneck. “To protect patient-centered care for the 28 million older Americans that rely on Medicare Advantage, physicians urge CMS to finalize the proposed policy changes and strengthen its prior authorization reform effort by extending its proposals to prescription drugs. We stand ready to continue our work with federal officials to remove obstacles and burdens that interfere with patient care.”
