番茄社区

Use of prior authorization in the Medicare Advantage (MA) program continues to increase, according to a .

More than 46 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees in 2022, up from 37 million in 2019, the report found. However, the average number of requests per enrollee was 1.7, the same as in 2019. "The rise in the total number of prior authorization requests corresponded to increasing enrollment in Medicare Advantage and so translated into a similar number of requests per enrollee," wrote report authors Jeannie Fuglesten Biniek, Nolan Sroczynski, and Tricia Neuman, all of KFF's Center on Medicare Policy.

Of the requests submitted, 90.4% were approved in full, while 7.4% were denied -- an increase from 5.7% in 2019, according to the report. And of those that were denied, about 10% were appealed, and of those, 83% resulted in the denial being overturned.

"While all Medicare Advantage insurers for at least some services, there is variation across insurers and plans in the specific services subject to these requirements," the researchers wrote. "In addition, insurers have the option of waiving prior authorization requirements for certain providers, for example, as part of risk-based contracts or through 'gold carding' programs that exempt providers with a history of complying with the insurer's prior authorization policies."

Not a Surprise

Healthcare groups said the report didn't surprise them. "Repeated investigations by [KFF] strongly suggest that the overuse of prior authorization controls by Medicare Advantage plans results in the denial of medically necessary healthcare," Bruce Scott, MD, president of the American Medical Association (AMA), said in an email to 番茄社区. "The KFF findings mirror physician experiences illustrated in the , which found that excessive authorization controls required by health insurers are responsible for serious harm when necessary medical care is delayed, denied, or disrupted."

Steven Furr, MD, president of the American Academy of Family Physicians (AAFP), noted that "prior authorizations and clinician burnout often go hand in hand." "As many practices struggle to balance the administrative burdens and responsibilities of running a practice amid considerable rising costs, closures, and staffing shortages, coupled with a lack of congressional action to address prior authorization, it's not surprising that burnout has increased and that the number of prior authorization requests are higher," he said in an email.

"We know that if 90% of prior authorization requests are approved, then these programs are not targeted efforts to ensure appropriate utilization," Furr continued. "Instead, they are arbitrary, unnecessary paperwork burdens that, at best, slow down access to care and increase burnout, and at worst completely deny access to care. Prior authorizations are harming patient care!"

Congressional Action On the Horizon

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), said that when it comes to Medicare Advantage, reducing the number of prior authorizations is "our top priority." (Disclosure: Gilberg is a member of the 番茄社区 editorial board).

"The vast majority of prior authorizations are ultimately approved, and this report is yet another strong piece of evidence as to their frivolous nature," he said in an email. "Prior authorization continuously ranks as the most burdensome regulatory issue facing medical groups, with prior authorization requirements in the MA program as more burdensome than those in both commercial insurance and Medicaid."

Like the AMA and AAFP, MGMA is supporting a bill now in Congress known as the , which has broad bipartisan support in both the House and Senate. That measure would:

• Establish an electronic prior authorization process
• Require HHS to establish a process for "real-time decisions" for items and services that are routinely approved
• Improve transparency by requiring Medicare Advantage (MA) plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials
• Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians

On the other side of the issue, Better Medicare Alliance, which represents MA plans, also supports the bill. "The cost of healthcare is a top concern for seniors, and prior authorization helps keep costs low for Medicare Advantage beneficiaries. But it shouldn't be a burden on patients," said Susan Reilly, vice president of communications at Better Medicare Alliance, in an email to 番茄社区. "We support common-sense efforts to streamline prior authorization for seniors, including the Improving Seniors' Timely Access to Care Act currently before Congress."

Addressing the CBO's Concerns

A of the bill passed the House on a voice vote in 2022, but it hit a roadblock in the Senate in the form of a from the Congressional Budget Office (CBO).

"By placing additional requirements on plans that use prior authorization, we expect [the bill] would result in a greater use of services," the CBO report said. "We expect Medicare Advantage plans would increase their bids to include the cost of these additional services, which would result in higher payments to plans." The CBO estimated that the bill would cost the federal government $16.2 billion over a 10-year period.

As a result, congressional supporters of the bill have now introduced a new version. "The bill sponsors have made several changes to lower the costs based on the input they received from the Congressional Budget Office," Katie Orrico, JD, CEO of the American Association of Neurological Surgeons, said in an email to 番茄社区. "While there are no guarantees, we anticipate that the changes should bring the cost down closer to zero. CBO will discount the costs to the extent that the bill mirrors the final rule CMS published earlier this year, thus paving the way for passage."

"The timing is uncertain at this time, but now that the bill has been introduced, we hope the CBO will swiftly analyze it, and Congress will advance it on a fast-track pathway," she added. "The alternative option is to incorporate this into any must-pass legislation this year." The current bill has 182 House cosponsors and 51 Senate cosponsors.

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