AAO urges CMS to suspend Medicare Advantage prior authorization processes
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Key takeaways:
- Medicare Advantage prior authorizations have delayed necessary treatments for patients.
- The American Academy of Ophthalmology urged CMS to suspend these prior authorization processes.
The American Academy of Ophthalmology has urged CMS to suspend Medicare Advantage prior authorization processes due to the delays they create for cataract surgeries and routine services.
The AAO supports attempts by CMS to simplify prior authorization (PA) processes, but “our experiences with Medicare PA in the hospital outpatient department make the Academy extremely concerned about CMS considering PA policies being rolled out to traditional fee-for-service Medicare,” Michael X. Repka, MD, MBA, AAO medical director for governmental affairs, told Healio/OSN.
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“Now is the time for policymakers to address prior authorization reform to ensure equal access to care for all Medicare beneficiaries,” he said. “The state where a Medicare Advantage beneficiary lives should not determine whether they can receive the care they need in a timely fashion, which is unfortunately the situation in Georgia and Florida right now with Aetna and Humana Medicare Advantage plans requiring PA for cataract surgery. The Academy urges CMS to finalize these recent proposed rules as quickly as possible.”
According to the AAO, requiring PA for routine and medically necessary services results in unnecessary treatment delays, worsens health outcomes for patients and draws on staff time for unwarranted administrative activities.
“We ardently oppose prior authorization under Medicare fee-for-service and urge CMS to suspend any existing PA policies on services not mandated by legislation,” Repka and David B. Glasser, MD, AAO secretary for federal affairs, wrote in a letter to CMS. “We believe that PA expansion in fee-for-service has the potential to harm Medicare patients’ access to necessary care and should not move forward without a specific legislative mandate.”
For the final proposed rule, AAO urged CMS to require responses within 7 days for nonurgent PAs and within 24 hours for urgent PAs, as well as to withdraw the proposed Electronic Prior Authorization Promoting Interoperability measure on the basis that it is unfair to score Merit-Based Incentive Payment System eligible clinicians and groups on technology that their electronic health records may not have.
“The Academy appreciates the Centers for Medicare and Medicaid Services proposing policies that would streamline and simplify the prior authorization process to ensure the timely provision of patient care,” Repka told Healio/OSN. “The agency has clearly listened to cries from patients and health care providers urging more oversight of the unscrupulous tactics Medicare Advantage plans use to deny medically necessary care. The proposed rule also reflects the concerns of Congress by including many elements of the Improving Seniors’ Timely Access to Care Act of 2021 (H.R. 3173/S. 3018), which had broad bipartisan support in the 117th Congress. We hope to see the bill reintroduced in the 118th Congress so that critical patient protections are codified into law.”
Editor’s note: This article was updated on March 29, 2023, to include comments from Michael X. Repka, MD, MBA.
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