MGMA presses CMS on prior authorization reform
MGMA said that current attempts by the administration to streamline prior authorization are a good start, but that more needs to be done.
Photo: Al David Sacks/Getty Images
The Medical Group Management Association is pressing the Centers for Medicare and Medicaid Services to reform the prior authorization process for healthcare services, calling it "routinely the most burdensome issue facing medical group practices."
In a recent letter to CMS, MGMA said that current attempts by the administration to streamline prior authorization are a good start, but that more needs to be done.
If CMS' rule is finalized, it would mandate that a prior authorization approval is valid throughout the entire course of treatment for a Medicare Advantage patient, and an MA plan can only deny coverage if it's backed by a physician or expert with the appropriate medical background. Further, prior authorization would be limited to confirming a diagnosis.
But provider groups, including MGMA, are saying the rule as proposed would still result in delays to patient care.
The group is urging CMS to apply the proposed clinical validity and transparency of coverage criteria policies to include prescription drugs; establish an oversight plan that will hold plans accountable for noncompliance; and include additional prior authorization reforms in future rulemaking, such as eliminating step therapy, requiring gold-carding programs and exempting medical groups participating in value-based models from prior authorization requirements.
WHAT'S THE IMPACT?
While supportive of CMS' efforts to move prior authorization away from being a tool to discourage care, MGMA said it doesn't believe that prior authorization is necessary to confirm diagnoses. For that reason, it opposes CMS' proposal calling for that, and said CMS must establish guardrails to prevent high volumes of prior authorization requests by MA plans.
One way to do this, said MGMA, is by implementing a "gold-carding" program.
"Gold-carding programs exempt providers from prior authorization requirements for certain services if they reach a particular approval rating over a period of time, thereby allowing physician practices to divert resources towards patient care," MGMA wrote. Last Congress, MGMA supported the GOLD CARD Act, which would exempt physicians from MA plan prior authorizations if they had 90% of requests approved in the preceding 12 months.
MGMA also said MA plans' prior authorization approvals must remain valid for the duration of the approved course of treatment. MA plans would have to provide a minimum 90-day transition period for any active course of treatment after starting it.
CMS states in its proposed rule that prescription drugs are not included within the scope of these prior authorization reform proposals. MGMA urged CMS to reevaluate that position, and extend the proposed clinical validity and transparency of coverage criteria policies to prescription drugs.
MGMA said it supports CMS' proposal to require Part D plan sponsors to comply with the National Council for Prescription Drug Programs' (NCPDP) Real-Time Prescription Benefit Standard Version 12, thereby allowing group practices to check prior authorization requirements at the point of prescribing.
The group also urged CMS to establish an oversight plan to enforce the implementation of the new requirements.
MGMA floated a couple of other proposals, including eliminating step therapy, otherwise known as "fail first," which requires patients to try and fail certain treatments before allowing access to more appropriate – and usually more expensive – treatments. "Step therapy puts the health plans in the driver's seat of a patient's care, undercutting the provider-patient decision-making process," MGMA wrote, saying it urges CMS to reinstate step therapy prohibition in MA plans for Part B drugs.
The group also wants to waive prior authorization requirements for providers who are participating in value-based models of care.
"Groups who are part of value-based care models are already incentivized to control costs and deliver high-quality care," MGMA wrote. "It is unnecessary and a further impediment to delivering care to require these group practices to go through the motions of seeking prior authorization approvals when their costs are already controlled."
THE LARGER TREND
CMS released the proposed rule on expanding access to health information and improving the prior authorization process on December 6. One reason for implementing the changes is physician and clinician burnout, said Surgeon General Vice Admiral Vivek Murthy.
Current prior authorization, with its requirements to fax information and signatures, causes delays and sometimes results in patients abandoning care, he said. Institutions have to hire people full time just to work on prior authorization, Murthy said. It is increasing clinician burden and driving burnout.
The proposed rule would require certain payers to implement an electronic prior authorization process for attachments and signatures. It would require implementation of a Health Level 7 (HL7) Fast Healthcare Interoperability Resources FHIR standard Application Programming Interface (API) to support electronic prior authorization.
Certain payers would be required to implement standards enabling data exchange from one payer to another payer when a patient changes or has concurrent insurance coverage, which is to help ensure that complete patient records are available throughout the transition, CMS said.
The proposed rule would also require insurers to provide reasons for the denial.
An Office of the Inspector General report that found MA plans denied prior authorization requests that met original Medicare coverage rules.
The third change would align prior authorization policy across Medicare, Medicare Advantage, Medicaid, CHIP and Affordable Care Act marketplace plans, according to CMS Administrator Chiquita Brooks-LaSure.
Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com
