AHA urges CMS to address prior authorization issues affecting Medicare Advantage payments

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The American Hospital Association has sent a letter to the Centers for Medicare and Medicaid Services requesting that the latter revise proposed regulations regarding prior authorizations, citing "issues" that may be affecting Medicare Advantage patients.

Specifically, the AHA is concerned about prior authorization procedures causing delays in care, potentially leading to negative clinical outcomes for patients.

"A prior authorization request is often the final barrier between a patient and the implementation of their provider's recommended treatment, making judicious processing of such transactions extremely important," the AHA wrote.

Current CMS rules allow Medicare Advantage organizations (MAOs) to take up to 14 days to respond to a prior authorization request, during which time a patient or provider is uncertain as to whether their planned treatment can go forward, according to the AHA.

The group called this delay in patient care unnecessary and unacceptable. In many instances, the AHA said, the patient is in the hospital awaiting transfer to the next site of care to continue their treatment, such as inpatient rehabilitation. These patients can sit unnecessarily in hospital beds for days or even weeks as MAOs process the prior authorization request.

The AHA contended these delays contribute not only to the degradation of a patient's condition, but waste health system resources and prevent hospitals from freeing up inpatient capacity. To combat the issue, the group recommended that plans be required to deliver prior authorization responses within 72 hours for standard, nonurgent services and 24 hours for urgent services.

Another point of contention with the hospital advocacy organization is the propensity for MAOs to inappropriately utilize prior authorization to delay access, a claim partially based on a 2018 report by the Department of Health and Human Services' Office of Inspector General showing 75% of MAO prior authorization and claims denials were overturned when appealed by providers between 2014 and 2016. 

As a result of these findings, the Inspector General recommended increased oversight of MAO prior authorization processes in order to ensure that beneficiaries could access appropriate treatment in a timely manner.

The AHA also criticized what it called "overly stringent medical necessity policies."

"The medical necessity determination needed to admit a patient to a hospital is often a significantly higher threshold for MAOs as compared to the 'two-midnight rule' CMS uses for its fee-for-service patients," the group wrote "Health plans frequently deny hospital requests for patient admission, despite having met the two-midnight criteria and having clear clinical justification for inpatient care. 

"This denial forces hospitals into a precarious situation in which they must admit the patient and hope to win on claims appeal or delay patients from medically necessary care while they navigate the plan's prior authorization appeal process."

The AHA urged CMS to establish increased oversight and enforcement of MA plans, and use data on prior authorization to identify outliers – those plans with disproportionately high usage of prior authorization and those with high rates of adverse determinations overturned on appeal – for audits. 

"This oversight would help fulfill the OIG report recommendation and help providers deliver timely and effective care that Medicare enrollees deserve," according to the letter.

WHAT'S THE IMPACT?

Prior authorization is a process whereby a provider, on behalf of a patient, requests approval from the patient's insurer before delivering a treatment or service. Although initially designed to help ensure patients receive optimal care based on well-established evidence of efficacy and safety, many health plans apply prior authorization requirements in ways that create delays in care, contribute to clinician burnout and drive up costs for the healthcare system, the AHA said. 

One of the most frustrating aspects for providers and patients, according to the organization, is the variation in prior authorization submission processes. Plans vary widely on accepted methods of prior authorization requests and supporting documentation submission. For each plan, providers and their staff should ensure they're following the right rules and processes, which may change from one request to the next.

THE LARGER TREND

Handling prior authorization requests electronically, rather than manually, can reduce the median time between submitting a PA request and receiving a decision. The result clocks in at around three times faster, for a time reduction of about 69%, according to findings presented in a March Zoom call by AHIP.

The analysis, handled in conjunction with independent nonprofit analytics firm RTI International, also found that faster time to patient care, lower provider burden and improved information for providers are among the benefits of electronic prior authorization capabilities.

The work examined 40,000 manual and electronic PA requests from health plans, finding that the COVID-19 pandemic has little statistical impact on the findings.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com