AHA Asks CMS to Waive Medicare Advantage Prior Authorization During PHE


CMS encouraged Medicare Advantage plans to waive prior authorizations during the public health emergency, but AHA urged the agency to make it a requirement instead of a suggestion.

The American Hospital Association (AHA) has asked CMS to work with Congress and require Medicare Advantage plans to waive prior authorization processes during the current and future public health emergencies (PHEs).

“While many plans worked collaboratively with provider partners to waive or relax onerous prior authorization requirements during the PHE, others did not, or only did so during the initial stages,” AHA wrote. “The continued use of prior authorization and other health plan utilization management policies by some plans throughout the pandemic exacerbated capacity issues, caused delays affecting patient care, and resulted in high rates of inappropriate denials.”

General acute care hospitals have faced capacity issues during the pandemic, especially during coronavirus surges. While hospitals provided critical care to COVID-19 patients, the facilities also dealt with extended stays from patients who could have sought appropriate care in another setting, but prior authorization stood in the way, AHA said.

For example, some patients in a general acute care hospital reached a recovery point where they could transfer to a long-term care hospital (LTCH), a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF). However, prior authorization requirements tended to delay these transfers or prevent discharge.

Delaying appropriate discharges created extra strain for hospital staff and consumed resources that providers could have directed toward critical COVID-19 patients, the letter noted.

Additionally, AHA said the PHE prior authorization waivers have mainly been inconsistent. Some Medicare Advantage plans applied waivers for only certain services or at different times during the pandemic. A handful of plans enacted restrictions for provider types, with some excluding post-acute care providers from waivers.

According to AHA, the use of prior authorization waivers was significantly higher among Medicaid managed care plans compared to Medicare Advantage plans, even when the same payer offered the plans.

Furthermore, AHA cited evidence revealing that Medicare Advantage beneficiaries were half as likely as Medicare fee-for-service beneficiaries to receive care at an LTCH, SNF, or IRF due to Medicare Advantage’s restrictive prior authorization requirements.

The letter also raised concern about how prior authorization requirements delay patient care due to the lengthy turnaround time between the request and the decision.

“Our members estimate that it takes MA plans who did not waive prior authorization requirements during the PHE approximately three days to respond to an authorization request for PAC,” AHA wrote. “The total turnaround time can be much greater for denials that include plan requests for additional information or require subsequent appeals.”

Excessive prior authorization requirements increased administrative burden and exacerbated the workforce shortage, AHA added. Oftentimes physicians and nurses must manage prior authorization requests, which diverts their attention from patient care.

Nearly 88 percent of physicians reported that prior authorization generated high or extremely high burden, and 93 percent said that the requirements sometimes, often, or always delayed access to necessary care for patients, according to data from the American Medical Association.

Finally, the letter said that the lack of transparency in prior authorization clinical guidelines makes it impossible for providers to anticipate what a health plan might request as evidence of medical necessity. This often leads to extensive back and forth between providers and payers to comply with health plan requests.

“Urgent and continued action is needed to ensure that health plans’ administrative processes do not impede patients’ ability to receive timely, quality, medically necessary care in clinically appropriate downstream settings,” AHA concluded. “This is more important than ever as we continue into our third year of a global pandemic, fighting new variants and surges, administering additional vaccine doses, addressing workforce shortages, and maintaining critical testing and treatment capacity.”

In a letter to CMS Administrator Chiquita Brooks-LaSure, AHA offered comments on the CMS 2023 proposed rule for the Medicare Advantage program. Specifically, the organization touched on the policies regarding prior authorization for hospital transfer to post-acute settings during public health emergencies.

During the pandemic, CMS allowed Medicare Advantage plans to relax or waive prior authorization requirements, benefiting many hospitals and health systems. However, the agency only encouraged plans to waive this process and did not mandate them to, generating concern from AHA.

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