May 09, 2019
Area(s) of Interest: Payor Issues and Reimbursement Public Payors
On May 8, 2019, the U.S. House of Representatives Appropriations Committee approved on a bipartisan basis language that calls on the Centers for Medicare and Medicaid Services (CMS) to implement Medicare Advantage prior authorization reforms.
Prior authorization is a cost- and utilization-control measure that requires physicians and other health care providers to obtain advance approval from a health plan before services can be delivered to patients. These reforms, included in the FY 2020 Labor HHS Appropriations bill, would scale-back Medicare Advantage plan prior authorization and some prescription drug step therapy, as these policies are causing patient care delays and increased administrative costs for physicians.
The committee specifically wants CMS to require Medicare Advantage plans to exclude from prior authorization requirements services that align with evidence-based guidelines and have historically high prior authorization approval rates. Medicare Advantage plans would also be required to report annually to the Health and Human Services Secretary a list of items and services that are subject to prior authorization, the percentage of requests approved and the average time for approval. The committee also urged CMS to work to increase the use of electronic prior authorization.
The bill now moves to the House floor and then to the Senate for final action.
The California Medical Association (CMA), American Medical Association and others in organized medicine have made widespread calls over the last two years for meaningful prior authorization reform. Current prior authorization programs and processes are costly, inefficient, opaque and in some cases hazardous. We look forward to working with CMS to create a more transparent efficient, fair and appropriately targeted prior authorization process.