Providers want more from CMS on prior authorization reform after proposed changes

Provider groups say new reforms proposed by the Biden administration to streamline prior authorization are a good start. 

But much more needs to be done—including creating gold-card programs that let providers skip prior authorization if they have a high volume of requests, they say. 

Several provider and payer groups submitted comments on a proposed rule outlining policy changes for Medicare Advantage (MA) and Part D set to take effect in 2024. One of the biggest changes is to clarify when and how MA plans can use prior authorization, a cost containment tool that requires physicians to get insurer approval before doling out certain items and services but has morphed into a major source of administrative burden for providers.

“Physician groups point to delays in prior authorization decisions, resubmission of prior authorization, inconsistent payer payment policies … and prior authorizations for routinely approved items and services as some of the most challenging aspects of prior authorization,” wrote the Medical Group Management Association (MGMA) in comments to the proposed rule that were due Monday.

If finalized, the Centers for Medicare & Medicaid Services' (CMS’) rule would mandate that a granted prior authorization approval remains valid for the entire course of treatment for a patient in MA. If an MA plan denies coverage for a request, it must rely on a physician or expert that has expertise in the appropriate field of medicine, CMS added.

The agency also proposed prior authorization must be limited to only confirming the presence of a diagnosis.

But provider groups say this still doesn’t address the problem that any prior authorization process “inherently delays patient care,” MGMA wrote. “CMS must establish guardrails to prevent high volumes of prior authorization requests by MA plans.”

One of these strategies could be gold-carding programs that exempt certain clinicians from prior authorization if they have an approval rating over a period of time. This would help ease the number of requests a physician must face.

A collection of more than 30 provider groups led by the American Medical Association wrote in comments that physicians and staff can spend an average of two business days a week just on prior authorization for a single physician. 

“This translates to less time with patients and contributes to an exhausted and overwhelmed workforce, underscoring the need to reduce overall [prior authorization] volume,” the comments said. 

Other additional reforms outlined in the comments include exempting physicians in a value-based care model from any prior authorization requests. These physicians are already incentivized to control costs, MGMA argues.

Another recommendation is to get rid of step therapy, another cost-containment tool that requires patients to try and fail certain treatments before going to a pricier one.

But some payers were wary of the prior authorization reforms outlined in the rule. 

The Blue Cross Blue Shield Association (BCBSA), which represents more than 30 Blues plans, wrote in comments that the changes are “highly prescriptive as they may restrict MA plans’ abilities to respond to emerging trends and design innovative solutions.”

The group said that while it supports CMS’ codification on the use of prior authorization, it doesn’t support the proposal to require approvals to be valid for the entire course of a patient’s treatment. 

This could lead to a provider continuing to offer services “no longer tied to the original approval,” the group said in comments. “Plans would also be unable to hold out-of-network providers accountable for the documents needed for an adequate transition period. This would increase the overuse of unnecessary medical care leading to higher costs and increased risks for patients.”

BCBSA also slammed CMS’ proposal to require MA plans to adopt policies that provide a minimum 90-day transition period for any ongoing course of treatment. It noted the goals of the practice are already achieved through prior authorization approvals being grandfathered in.

“Under CMS’ new proposal, a plan would need to pay a provider irrespective of whether the provider can demonstrate a prior approval was achieved under the previous plan,” it said.

The call for more reforms comes as the agency has proposed another regulation that would mandate plans across government programs such as MA, Medicaid managed care and Affordable Care Act marketplace exchanges to adopt electronic prior authorization.