The Texas Medical Association’s years of lobbying for prior authorization reform paid off with the passage of Texas’ “gold-card” law in 2021. Now the framework is gaining traction at the federal level, where a proposal would ease onerous preapproval requirements under certain public health plans.
The Centers for Medicare & Medicaid Services’ (CMS) proposed rule aims to “improve the electronic exchange of health care data and streamline processes related to prior authorization” under Medicare Advantage, Medicaid, and Children’s Health Insurance Program (CHIP) plans, among others, according to an agency fact sheet.
TMA "sincerely thanked” CMS for its proposal, saying it would improve patient access to care and reduce some of physicians’ administrative burden related to prior authorizations, in a March 13 comment letter. But the association also pushed the agency to go further.
“TMA calls on CMS to propose regulations that apply such improvements to the prior authorizations for all health plans under the agency’s purview,” TMA President Gary Floyd wrote.
Specifically, CMS’ proposed rule would:
- Make prior authorization data available to patients;
- Require payers to provide a specific reason for denying prior authorization requests and to publish aggregated preapproval data;
- Kickstart consideration of a gold-carding program, drawing on Texas’ TMA-backed law for inspiration; and
- Encourage EHR vendors to comply with an existing requirement that their products meet electronic prior authorization transaction standards.
TMA welcomes these regulatory changes, which Dr. Floyd wrote were “a needed and critical step forward in improving the prior authorization process.”
In addition, the association recommended CMS:
- Establish a process to ensure payers comply with such requirements, including a means for physicians to report noncompliant payers;
- Restrict retrospective review, which “leaves the physician uncompensated for services previously approved by the payer;”
- Convene a workgroup to monitor the implementation of these new regulations; and
- Extend these proposed prior authorization reforms to prescription drugs.
CMS further addressed medicine’s prior authorization concerns by issuing in early April a separate but related final rule specific to Medicare Advantage (Part C) and prescription drug (Part D) plans, which takes effect in 2024.
Among other provisions, the rule requires Medicare Advantage plans to:
- Cover the same items and services as traditional Medicare;
- Use prior authorizations only to confirm the presence of diagnoses or other medical criteria or to ensure that an item or service is medically necessary; and
- Ensure preapprovals remain valid for the duration of treatment, including in the case of plan changes.
TMA and others in organized medicine endorsed the proposed version of this rule while still pressing CMS to do more, including by extending its updated coverage criteria policy to prescription drug 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.
TMA has long amplified physicians’ concerns about the patient and financial harms caused by health plans’ overzealous use of prior authorizations. A recent survey by the American Medical Association found 86% of physician respondents reported such requirements led to higher use of health care resources, driving up costs, and 89% said they had a negative impact on patient outcomes, in part because they delayed care.
Read all of TMA’s comment letters to state and federal leadership in TMA’s advocacy center.