Physicians caring for Medicare patients soon may find relief from onerous prior authorization requirements that frequently delay, discourage, or drive up the costs of care, thanks to proposed regulations governing Medicare Advantage (Part C) and prescription drug (Part D) plans.
The Texas Medical Association recently joined the American Medical Association and 117 national specialty and state medical associations in urging the Centers for Medicare & Medicaid Services (CMS) to finalize and adopt the reforms.
The CMS proposal responds to medicine’s longstanding concerns by requiring Medicare Advantage plans to, among other provisions:
Cover the same items and services as traditional Medicare;
Use and make public current evidence when developing new clinical coverage criteria; and
Ensure prior authorization approvals remain valid for the duration of treatment, including in the case of plan changes.
The proposal also encourages Medicare Advantage plans to implement gold-carding programs to exempt eligible physicians from prior authorization requirements, drawing inspiration from Texas’ 2021 law, which TMA proposed and championed.
On the Part D front, CMS proposes mandating such plans automate prior authorization-related tasks, which would allow physicians to review coverage criteria and drug formulary status as part of the prescription process.
TMA and the other signatories welcomed the effort while pressing CMS to go further, including by extending its proposed coverage criteria policy to Part D plans.
“Thank you for listening to our calls for [prior authorization] reform and proposing policies that will help right-size these requirements that so often stand in the way of medically necessary care,” they wrote in a Feb. 13 letter to CMS Administrator Chiquita Brooks-LaSure.
Medicine pointed to several studies showing the damaging impact of prior authorizations on patients, including a 2021 AMA survey, which found 93% of physician respondents reported care delays related to such requirements. More recently, the U.S. Office of Inspector General reported 13% of prior authorization requests denied by Medicare Advantage plans met Medicare coverage rules.
Prior authorizations also contribute to physician burnout, TMA and others noted, with 88% of AMA survey respondents describing their burden related to preapprovals as high or extremely high.
“We urge CMS to finalize these important changes ... and look forward to continuing to work with you to reduce the burden of [prior authorization] as it relates to all care in all health care markets,” medicine wrote.
In addition to the federal effort, TMA is focused on prior authorization reform at the state level, where its legislative priorities include:
Cleaning up the 2021 Texas gold-card law to ensure it holds eligible health plans accountable;
Requiring health plans to provide 24/7 prior authorization processing, including on holidays and on weekends; and
Eliminating prior authorizations for patients with chronic conditions, for whom gaps in care are especially harmful.
Emma Freer
Associate Editor
(512) 370-1383