Earlier this year, the Centers for Medicare & Medicaid Services (CMS) began requiring Medicare Advantage (MA) organizations to publicly report prior authorization data for use by people with Medicare, researchers, and advocates. CMS has released welcome new guidance to improve how and where this information must be reported. These updates are an important and timely step: New KFF polling finds consumers continue to struggle with burdensome prior authorization requirements.
The Currently Reported Information Is Hard for Beneficiaries to Navigate
Starting April 1, a 2024 regulation requiring MA and other private plans to publicly report and display specific data around prior authorization went into effect.
MA organizations must now display how often they use prior authorization, deny requests, and overturn on appeal, as well as their processing times for these requests. The reporting applies to both standard prior authorization requests and ones that are expedited because of an urgent situation.
MA organizations must now display how often they use prior authorization, deny requests, and overturn on appeal.
However, the data are not reported plan-by-plan. Instead, they are reported at the contract level, meaning information from several plans can be mixed together and potential enrollees cannot see what metrics apply to specific plans, undermining the utility of this data in beneficiary decision-making.
And the information can be hard to find. Some organizations tuck it into unexpected corners of their websites or even place it on password-protected sites.
In addition to these prior authorization metrics, MA organizations are also required to publicly post lists of services that require prior authorization. While this is good information, it has not yet been made deeply meaningful for the average consumer.
The New Guidance Makes Improvements
In its new guidance, CMS flags that burying or password-protecting the data does not meet the publication requirement.
Burying or password-protecting the data does not meet the publication requirement.
To enhance accessibility, the agency urges MA organizations to use visual formats and supplies a template for one way to organize the data.
The guidance also notes that a prior authorization list “must identify the medical items and services in a manner that is understandable to patients and providers,” to make this reporting more useful.
What’s Still Missing
The guidance should improve the accessibility of this information, but more should be done to eliminate reporting and publication gaps.
For example, the data include prior authorization practices around Part B drugs, but not Part D drugs, leaving this important category without needed transparency.
More should be done to eliminate reporting and publication gaps.
The reporting should also be done at the plan level. This would better allow enrollees to determine which plans are the best fit. It would also strengthen oversight by revealing outlier plans and behaviors.
The data remain limited by lack of detail around what services and populations are most affected by prior authorization. Are certain services targets? Are there concerning patterns of prior authorization and denials that may reveal discriminatory plan behaviors or designs? MA enrollees deserve answers to these questions.
Prior Authorization Remains a Burden for Consumers
The data improvements come alongside recent KFF polling showing that beyond affordability, insured adults view prior authorization as their greatest obstacle to care. Even though enrollees can appeal erroneous denials, those appeals take time, delaying access and increasing stress.
Even though enrollees can appeal erroneous denials, those appeals take time, delaying access and increasing stress.
It’s an even greater problem for people with chronic conditions and others with high health needs. Not only do their more frequent interactions with the health care system put them at greater risk of exposure to prior authorization, they may also be less able to tolerate care disruptions or delays. Past research from the U.S. Government Accountability Office (GAO) has shown that when people with MA get sicker, they are more likely to leave MA for Original Medicare. GAO notes these disenrollments “may indicate potential issues with their care” such as increased administrative red tape in MA.
Beneficiaries Need Prior Authorization Reforms
At Medicare Rights, we support significant prior authorization reforms. Each year on our national helpline, the majority of questions we receive about coverage denials are related to MA. Callers are often struggling with what to do next, from trying to unpack confusing plan communications to navigating the complex MA appeals process.
Even successful appeals come at a cost, including care delays and negative health outcomes.
For all, coverage denials can be extremely stressful and disruptive, often forcing beneficiaries to choose between seeking other care, paying out of pocket, going without, or getting embroiled in a daunting appeals system. Too often, these denials are inappropriate. And even successful appeals come at a cost, including care delays and negative health outcomes.
These plan policies must not be used merely to deny or dissuade enrollees from receiving necessary care. Services must never be automatically denied whether by a human, AI, or algorithms.
We would also welcome a larger conversation about the experiences, efficacy, and tradeoffs of prior authorization, including potential alternatives.
People with Medicare must not face delays and denials that keep them from the care they need.
The post More Clarity on the Horizon for Medicare Advantage Prior Authorization, Burden Will Remain appeared first on Medicare Rights Center.
