February 15, 2023
The California Medical Association (CMA) joined the American Medical Association (AMA) and more than 100 leading medical societies to voice support for the meaningful prior authorization reforms proposed by the Centers for Medicare and Medicaid Services (CMS) that will increase access to medically necessary care.
CMA and the physician groups sent a joint letter to CMS Administrator Chiquita Brooks-LaSure lauding the agency for incorporating the feedback of physicians and other stakeholders into the proposed rule and urged CMS to finalize the rule, which includes the following provisions:
- Medicare Advantage (MA) plans may only use prior authorization to confirm diagnoses or other medical criteria and ensure the medical necessity of services.
- MA beneficiaries must have access to the same items and services as they would under traditional Medicare. When no applicable coverage rule exists under traditional Medicare, plans must use current evidence from widely used treatment guidelines or clinical literature for internal clinical coverage criteria, which must then be made publicly available.
- MA plans must establish a Utilization Management Committee to review their clinical coverage criteria and ensure consistency with traditional Medicare guidelines.
- MA plans cannot deny care ordered by a contracted physician based on a particular provider type or setting unless medical necessity criteria are not met.
- MA plans’ prior authorization approvals must remain valid for the duration of the course of treatment.
- MA plans must provide beneficiaries with a 90-day transition period where a PA would remain valid for any ongoing course of treatment when beneficiaries change plans or enter MA.
- After PA approval, MA plans cannot retroactively deny coverage for a lack of medical necessity.
Prior authorization has been a longstanding obstacle to patients receiving easily accessible care, and there has been ample evidence of this in Medicare Advantage plans:
- AMA’s most recent survey on prior authorization found that 93 percent of physicians reported care delays while waiting for health insurers to authorize necessary care.
- A review conducted by the Inspector General of the U.S. Department of Health and Human Services (HHS) found that Medicare Advantage Organizations improperly denied 13 percent of the prior authorization requests and 18 percent of payment requests.
- A Kaiser Family Foundation analysis found that, in 2021, Medicare Advantage plans wholly or partially denied 2 million of 35 million requests (about 6%). Of the 11 percent of denials that were appealed, 82 percent were partially or fully overturned.
CMA is encouraging physicians who have been frustrated with administrative headaches and their impact on your patients to share their stories. By adding your voice to help reform the prior authorization process to ensure that patients receive the care they need — when they need it.