AHA pushes CMS to include MA plans, tighter turnarounds in proposed prior authorization rule

Doctor and patient talking and discussing health treatment while sitting at the desk. Physician pointing into tablet pc.
In new comments, hospitals reiterated their general support for the Centers for Medicare & Medicaid Services’ proposed prior authorization rule while homing in on some of its initial arguments that the agency could be doing more to improve outcomes among a greater number of patients. (andrei_r/GettyImages)

The American Hospital Association (AHA) has formalized its request that the Centers for Medicare & Medicaid Services’ (CMS') proposed regulations aimed at streamlining prior authorizations extend to Medicare Advantage plans, establish when prior authorization may be applied, further reduce response timelines and include stricter oversight of unnecessary delays.

Introduced in December, CMS’ proposed rule (PDF) would require payers in Medicaid, the Children’s Health Insurance Program (CHIP) and qualified health plans on the Affordable Care Act's exchanges to build application programming interfaces to limit the administrative burden on providers submitting prior authorization requests.

These and other requirements in the proposed rule simplify the exchange of electronic documentation and hasten the speed with which providers receive a response so they can move forward with treatment, CMS said at the time.

The tentative regulation initially drew concerns from payers and applause from providers. The former argued that compliance would place an uneven and expensive burden on payers and health IT vendors, while the latter said the rule would stamp delays in treatment and create a more standardized submission process across various plans.

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In a Tuesday letter to CMS Administrator Chiquita Brooks-LaSure, AHA reiterated its general support for the proposed rule while homing in on some of its initial arguments that the regulation could be doing more to improve outcomes among a greater number of patients.

Chief among these critiques was the “extremely troubling” exclusion of MA plans from the proposed requirements. AHA noted in its comments that roughly a third of all Medicare beneficiaries, about 22 million people, are enrolled in a MA plan and that the Congressional Budget Office projects that share to increase to 47% by 2029.

“The proposal establishes that impacted plan beneficiaries, including those belonging to managed care plans, would experience improved efficiencies in the manner in which they receive care by reduced timelines and procedural improvements,” AHA wrote. “By excluding [MA organizations], the agency would be withholding these benefits from many Medicare beneficiaries.”

AHA’s letter went on to “strongly encourage” CMS to set a concrete requirement on when prior authorization should or should not be necessary. Services that overwhelmingly are approved represent an opportunity to avoid delays and administrative burden, the group wrote.

“We urge CMS to modify the proposed regulations to require MAOs to automatically consider a service authorized when the provider for that service has a history of prior authorization approval of 90% or greater,” AHA wrote. “The [MA organization] would still be permitted to require a provider to request prior authorization in instances where the provider historically has not met that threshold. This approach would go a long way in reducing unnecessary care delays and clinician burden while giving the plan the ability to ensure care adheres to the patient’s coverage rules.”

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Prior authorization decision timelines of seven days for standard requests and 72 hours for urgent cases also weren’t enough for the provider group.

Citing care delays and expenses that are particularly unnecessary “as the industry implements technology improvements that enable timely information exchange,” AHA called for a 72-hour deadline for standard, non-urgent requests and a 24-hour turnaround for urgent services.

AHA wrapped up its comments by highlighting Office of Inspector General data showing that the majority of MA plan prior authorization and claims denials were overturned when appealed. MA plans and other insurers, AHA wrote, “frequently establish overly stringent medical necessity policies that prevent patients from obtaining necessary care” using the prior authorization process.

As such, AHA urged CMS to implement greater data-driven oversight of outlier plans “with disproportionately high usage of prior authorization and those with high rates of adverse determinations overturned on appeal” for potential enforcement.

“The AHA urges CMS to reign in this inappropriate health plan usage of roadblocks that delay access to or jeopardize coverage for essential care,” it wrote.

CMS’ proposed rule places a Jan. 1, 2023, deadline for payers to implement their application programming interfaces.

The agency’s nearly 100-page rule did briefly see the light of day as a finalized regulation. In January, the Trump-era agency released the rule into the wild just five days before handing over the reins to the Biden administration, which quietly withdrew the finalized rule in mid-February as part of its freeze on last-minute regulations finalized by the outgoing team.