番茄社区

WASHINGTON -- Prior authorization, that oft-maligned process of getting insurer approval prior to performing a procedure or prescribing a drug, is in the spotlight once again, on several fronts.

On Capitol Hill, the issue began to bubble up in late April, when the Department of Health and Human Services (HHS) Office of Inspector General (OIG) examining Medicare Advantage plans' denials of prior authorization requests.

"Although MAOs [Medicare Advantage organizations] approve the vast majority of requests for services and payment, they issue millions of denials each year, and CMS [the Centers for Medicare & Medicaid Services] annual audits of MAOs have highlighted widespread and persistent problems related to inappropriate denials of services and payment," the office .

Internal Criteria, Overlooked Documentation

The office looked at 250 prior authorization denials and 250 payment denials from a single week in June 2019 and found that "MAOs sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the requests met Medicare coverage rules." In addition, "MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules," the report said.

Among the 13% of denied prior authorizations that would have met Medicare coverage rules, the OIG said it found two common causes of denials:

"First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary," the report noted. "Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the existing beneficiary medical records were sufficient to support the medical necessity of the services."

Medicare Advantage plans also are the target of the , which would require more transparency for MAOs' prior authorization policies and direct the HHS secretary to establish an electronic prior authorization program. Although the bill was originally introduced in the House in 2021, it just recently reached the required 290 votes for some form of House action. If the measure is not assigned to a House committee within 25 days, the bill sponsor can request a floor vote. A in the Senate has 30 co-sponsors.

The Better Medicare Alliance, a lobbying group for Medicare Advantage plans, for the House bill on May 26, calling the measure a "commonsense solution that builds on the work the Medicare Advantage community has been doing to streamline prior authorization for seniors."

"We are on the cusp of making a truly impactful change to our healthcare system," Rep. Suzan DelBene (D-Wash.), one of the bill's chief sponsors, told 番茄社区 in an email. "The outdated prior authorization process still relies on faxing documents and multiple phone calls for procedures that are almost universally approved."

"Now with over 290 cosponsors in the House and support from the broad cross-section of the healthcare field, we are ready to get this all the way to President Biden's desk. I expect a House vote this summer and I am confident our Senate partners can move the legislation from there," she said. "Time is of the essence, though, with limited legislative days left in this Congress."

AMA Enters the Fray

The American Medical Association (AMA), which supports the House bill, also got into the fray, on May 24 of its 2018 prior authorization survey; the update used data from 2021. The survey found that 84% of respondents said prior authorizations for medical procedures had increased substantially over the past 5 years; the same percentage said that also was true of prior authorizations for prescription drugs.

AMA president-elect Jack Resneck, MD, told 番茄社区 that the issue is a top legislative priority for the organization.

"It's just an incredible, exponentially growing burden for doctors and for patients," he said in a phone interview at which a public relations person was present. "We have to believe something will get better as a result of all our work. As I travel around the country talking to my physician colleagues, and as I interact with my own patients, it's really the number one frustration with the healthcare system."

Resneck, a dermatologist, gave an example from his own practice. "I had a patient with full-body eczema; he was pretty miserable," he said. "This patient had failed all [the older, less expensive medications] and was on a newer biologic. It was life-changing. The person was a new human being, productive citizen, back at work, and being able to be present with their kids."

But Resneck suddenly got a notice from the patient's health plan saying the prior authorization for that drug had expired, so he filled out all the forms and explained how well the patient was doing on the new medication.

"I get back a rejection," said Resneck. "What does the rejection say? 'The patient no longer meets the disease severity criteria' ... I just decided I wasn't going to let this one go." He managed to get the drug approved again, "but it took hours and hours of phone calls and letters. This is just not OK."

Resneck is frustrated that little progress has been made since January 2018, when provider and insurer groups pledging to improve the prior authorization process.

"I think it hasn't moved because health plans don't want to spend the money to take care of their beneficiaries. And that is really the only explanation that I could come up with ... [The consensus statement] had a lot of reasonable common sense-reforms to right-size this prior auth[orization] mess. But insurers have made no progress enacting those principles," he said.

Ruth Williams, MD, a practicing ophthalmologist and the former CEO of the Wheaton Eye Clinic in Illinois, is especially frustrated with the way insurers use prior authorization for procedures such as cataract surgery.

"There is definitely a role for prior authorization; there's a long history of it being used appropriately and for good reason," she said. However, it should not be used in blanket fashion for something like cataract surgery "that is one of the most common surgeries in America, with about 4 million cases done per year."

She mentioned the case of a retired college professor, age 71, whose prior authorization request for cataract surgery was denied because she had 20/60 vision. "It was just maddening because she really, really, really needs cataract surgery," she said. "We don't know why it was denied .... [insurers] are incredibly opaque about what their decision-making process is."

Pushback on the House Bill

Some insurers are pushing back on the House legislation. "Unfortunately, certain provider organizations are targeting the MA program and its sustained success to advance their own political agenda and secure financial gains for their members," Matthew Eyles, president and CEO of America's Health Insurance Plans (AHIP), a lobbying group for health insurers wrote May 27 to CMS administrator Chiquita Brooks-LaSure. "As the largest advocacy organization representing health insurance providers, including MA plans that today serve tens of millions of Americans, I am writing on behalf of AHIP to correct the record, refute false and misleading reports being spread by these disinformation campaigns, and reaffirm our strong commitment to put patients and consumers first."

"Even doctors agree that variations in treatment can lead to unnecessary, costly, or inappropriate medical treatments that can harm patients," Eyles said. He cited a , which found that two-thirds of physicians themselves believed that at least 30% of the healthcare services they delivered were unnecessary.

"What would motivate provider organizations like the ... American Medical Association to undermine the MA program, challenge its broad bipartisan support, and tarnish the program's reputation? The answer is both evident and simple: They seek to undermine the valuable quality-improving, cost-saving, and waste-reducing tools of the program for their own financial benefit," Eyles added.

He also addressed the OIG report, noting that "Of the ... 13% of prior authorization requests that were denied – only 33 cases in the OIG's sample – seven of them were reversed within 3 months, often as part of the plan's appeals process."

"The main concern about many of those cases was not that they were improper, but rather that more guidance from the government was needed on criteria that plans can use to make coverage determinations," he continued. "CMS indicated that it will provide such guidance – and we agree that this is an important next step. In the end, the full findings of the OIG report are not an indictment of prior authorization, but rather a compelling story of value and access."

Also on Capitol Hill, the Office of the National Coordinator for Health Information Technology (ONC) from its Health Information Technology Advisory Committee with 13 recommendations for how the ONC Health IT Certification Program "could incorporate standards, implementation specifications, and certification criteria related to electronic prior authorization."

An ONC spokesperson said the agency will use the report "to inform potential future rulemaking" in this area and also will "share the recommendations in the report with other parts of HHS that are seeking to address issues related to prior authorization."

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