Prior Authorization Reform in Medicare Advantage

Prior Authorization Reform in Medicare Advantage | Case Studies | AllZone Management Services Inc.

Prior Authorization reform in Medicare Advantage would help relieve administrative burden for medical groups and reduce patient care delays, MGMA said.

The Medical Group Management Association (MGMA) has urged CMS to implement policies that support prior authorization reform and value-based care contracts within the Medicare Advantage program.

MGMA submitted comments to CMS Administrator in response to a request for information on Medicare Advantage. In the letter, which RevCycleIntelligence received by email, the organization stressed the importance of prior authorization reform and value-based contracting.

According to MGMA, prior authorization requirements create significant burden for medical groups and cause treatment delays for patients. The increasing requirements and a lack of automation in payers’ prior authorization processes frequently lead to administrative challenges for staff.

MGMA believes implementing changes in the Medicare Advantage program will help reform prior authorization and reduce costs, burden, and care delays.

The organization presented several recommendations for CMS. First, CMS should publish the Interoperability and Prior Authorization for MA Organizations, Medicaid and CHIP Managed Care and State Agencies, FFE QHP Issuers, MIPS Eligible Clinicians, Eligible Hospitals, and CAHs proposed rule.

This rule would streamline prior authorization processes in Medicare Advantage plans if finalized. However, the proposed rule stated that health plans should respond to medical groups within 72 hours for an urgent prior authorization and within seven days for a standard prior authorization. MGMA believes these timeframes should be shortened.

Second, CMS should implement recommendations included in a past report from the HHS Office of Inspector General (OIG). The report found that Medicare Organizations delayed or denied beneficiaries’ access to care even when the requests met Medicare coverage rules. OIG recommended that CMS update audit protocols and take steps to address issues that could lead to errors.

MGMA also suggested that CMS reinstate step therapy prohibition in Medicare Advantage plans for Part B drugs. Step therapy requires patients to try certain treatments before gaining access to more appropriate treatments. According to MGMA, this undercuts the provider-patient decision-making process and gives health plans more control of patient care.

Finally, MGMA has requested that CMS increase oversight of Medicare Advantage prior authorization processes and require transparency of payer prior authorization policies and establish evidence-based clinical guidelines available at the point of care.

The letter also highlighted how CMS could take action to improve participation in value-based contracts within the Medicare Advantage program.

“In contrast to fee-for-service Medicare, MA has the additional flexibilities to meaningfully incorporate value-based care principles into payment arrangements to support the transition to greater participation in such models,” the letter stated. “MGMA appreciates the agency’s continued focus on improving the MA program and critically evaluating how value-based care is an important tool within MA and can be improved in future rulemaking.”

Value-based care contracts vary by plan, practice, and specialty and can be complex for some medical groups.

When evaluating value-based contracts, practices should clearly define roles and responsibilities, analyze contract performance, review data, and develop collaborative relationships with payers, MGMA said.

CMS should focus on supporting primary care Medicare Advantage contracts to help further value-based contracting. In addition, MGMA recommended the agency collect more information from Medicare Advantage plans about the application and successes of value-based contracts.

The letter also suggested that CMS provide additional support to smaller and rural practices regarding value-based contract participation. These facilities are less likely to have access to the resources needed for value-based contracting and tend to provide care for underserved populations who would benefit from value-based care.

For More Information:  Mgma calls for prior authorization reform in medicare advantage