Biden Administration Tackles Prior Authorization Again

This week, Medicare Rights submitted comments on a proposed rule that would give Medicare Advantage (MA) enrollees and potential enrollees more information about plans’ prior authorization practices and processes.

This proposed rule comes at an important time as MA plans face greater scrutiny of their use of prior authorization and other tools that delay or even deny access to care. In some cases, the care is both medically necessary and would have been covered if the person had been in Original Medicare. These barriers to care can cause some to seek alternative coverage, disenrolling from their plan or from MA entirely.

Research indicates the rate of people leaving MA plans for either another plan or for Original Medicare is on the rise. Most recently, the Commonwealth Fund reports MA plan disenrollments are up from 10% in 2017 to 17% in 2021, and much of that may be spurred by prior authorization and similar practices: “An average of 18 percent of beneficiaries who disenrolled from an MA plan indicated that problems getting the plan to cover services caused them to leave the plan. This could include difficulty in getting claims paid, problems with the approval process, denial of services, or the inability to get needed care.”

In 2021, over two million prior authorization requests were denied, and only 11% were appealed. This suggests many abandon the daunting appeals process altogether and that millions are not getting the care they need. Over 80% of the appealed denials were overturned, but even successful appeals come at a cost, taking time and resources that some beneficiaries cannot afford.

The proposed rule is the second step in recent months the Centers for Medicare & Medicaid Services (CMS) has taken to try to remedy some prior authorization problems. The first was a proposal we strongly supported to clarify how MA plans must treat Medicare-covered services and what processes they must use to make prior authorization determinations.

In this follow-up proposed rule, CMS proposes to require MA plans and some other public program insurers to improve transparency and their communications with consumers, providers, and the public. This would include providing more information about the status of prior authorization requests, giving better guidance about what information is needed for a successful prior authorization request, and releasing data about plan rates of requests, denials, and other information that might be valuable to prospective enrollees and the public.

We also strongly supported these proposals and urge CMS to swiftly put them in place. Currently, there is too little information available about how MA plans do business. These new requirements might help some people choose between plans, but we urged CMS not to use it as an excuse to shift oversight responsibilities to enrollees. CMS must conduct rigorous review of the data the plans would be required to provide to ensure enrollees are getting the care they need.

Read the proposed rule on prior authorization and our comments.

Read more about the problems of prior authorization.

Read more about MA’s denial of medically necessary care.