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  • APTA Adds Its Voice to Coalition Calling for Medicare Advantage to Rein in Prior Authorization

    With nearly a third of the total Medicare population enrolled in a Medicare Advantage (MA) plan and growth expected to continue, it's time for the public-private hybrid system to evolve and move away from excessive use of prior authorization—that's the message being delivered to the Centers for Medicare and Medicaid Services (CMS) from a coalition of health care and consumer organizations including APTA.

    In an April 10 letter to CMS Administrator Seema Verma, the Coalition to Preserve Rehabilitation (CPR) writes that MA's uses of prior authorization "may be sources of increasing barriers to accessing needed care, particularly inpatient and outpatient rehabilitation services and devices, for beneficiaries nationwide." The coalition argues that in many cases, prior authorization "often serves as an unnecessary delay for beneficiaries seeking medically necessary care, and often results in no cost savings to the plan."

    Addressing the issue sooner rather than later is important, according to CPR, if for no other reason than MA's rapid growth, which is expected to continue from 19 million beneficiaries in 2017 to a projected 32 million by 2028. "The fast pace of growth of this program suggests the need for greater scrutiny of mechanisms imposed by these plans to manage services utilization, such as prior authorization," the coalition writes.

    While the letter acknowledges that prior authorization can be appropriate in some instances, the system increasingly is being overused, often in circumstances that are "difficult to justify" such as rehabilitation services and devices that are "unlikely to be overutilized and often need to be provided in a timely manner in order to maximize their medical efficacy."

    Adding to the problem, according to CPR, are recent moves by managed care plans to farm out benefits management to companies that are incentivized to save money by denying services.

    The letter suggests that CMS take its cue from the private insurance industry, which has been moving away from prior authorization—or at least taking a closer look at which prior authorization policies get in the way of medically necessary care. The coalition also recommends that CMS impose greater oversight of MA plans, with "stronger directives to MA plans to limit the use of prior authorization to services that are demonstrably overutilized."

    In addition to APTA, the 28 CPR members that signed the letter include the American Association of People with Disabilities, the American Occupational Therapy Association, the Brain Injury Association of America, the Epilepsy Foundation, the Michael J. Fox Foundation for Parkinson's Research, and the Paralyzed Veterans of America. APTA will monitor this issue and share developments as they arise.

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    • That is a move in the right direction. I hope someone points out that seniors are choosing managed care Humana plans, but they do not realize that is what they are choosing. Orthonet has hurt individuals with cancer and progressive diseaes by denying services that are needed.

      Posted by Karen on 4/16/2018 10:35 PM

    • Medicare Advantage plans in our experience are like most private insurance plans. They require too much pre-authorization for too few number of visits, with slow, low or no pay reimbursement models, randomly setting their computer algorithms to pick 2 -3 codes they'll pay for in no particular order, or will pay or drop codes that are higher in validity for what we perform regardless of what they are. It's another 'slice and dice' insurance product and absolutely NOT Medicare's equivalent! We're recommending are client base to not insure with them if they can afford to stay on "regular" M.C. with a "regular" and reliable secondary payor.

      Posted by Larry Greenberg on 4/18/2018 3:51 PM

    • "Adding to the problem, according to CPR, are recent moves by managed care plans to farm out benefits management to companies that are incentivized to save money by denying services." THIS.

      Posted by Becky on 4/19/2018 12:49 PM

    • I treat outpatients in their homes. In network with all insurance companies and never need authorization.

      Posted by Philip Bergold on 4/19/2018 12:52 PM

    • They should at least make post surgical patients not have to be pre-authorized. It is SO important they get treatment on time. It would be interesting to make insurance companies legally responsible if patients have negative post surgery results due to lapse in care, untimely start of care due to preauthorization time lags/ denials.

      Posted by Becky Rainwater PT on 4/19/2018 1:56 PM

    • Yesterday afternoon, I spent 40 minutes on the phone with EviCore then BCBS of Michigan then back to EviCore to secure prior authorization for OP PT services for a Medicare "Advantage" plan beneficiary. I'm not seeing the "Advantage" here, except for Blue Cross Blue Shield of Michigan and their co-conspirators at EviCore. Last fall I attended a 'provider outreach' event in Novi where BCBS reps delivered a lovely presentation on how fast, easy and really really good it was going to be come 1/1/2018 when they and EviCore implemented this cool new web portal to make the PA process a snap for providers. Umm, yeah. I see. Meanwhile, in the real world, we continue to waste our most precious resource (time) getting misdirected by poorly trained representatives, jumping through arbitrarily contrived hoops and advocating for some of our nation's most vulnerable people. In their massive marketing campaigns I've yet to see an "Advantage" plan provide transparent information to potential beneficiaries. "We offer all the same coverages as traditional Medicare at half the cost! Plus a free gym membership and this snazzy hat! Woo hoo and hurray for you!!" Conspicuously absent are the little details like: "if you should happen to need post acute SNF or HH services, we'll have representatives standing by to pressure providers into meeting artificially created and financially driven benchmarks to limit your access to medically necessary services! But wait folks, that's not all! When you end up back in the hospital, we'll deflect responsibility and point to the providers for not providing proper you with the proper care! But wait! Our practices also guarantee that you'll receive medical services from providers who are beholden to our ever changing "Prior Authorization Requirements", Yes, its true! When you and your family are in crisis mode, before we agree to pay for anything on your behalf, we'll require the prospective providers to submit redundant information so that we, at our leisure, can determine if your doctor has your best interest in mind, or if the one we pay knows better. But then, and this is the part that'll surely seal the deal, after delaying and limiting your access to care, we will hire 3rd party "reviewers" who will be paid to find or invent creative reasons to justify taking the payment we made to your providers back! So not only do we make it hard for you, your family and your health care providers on the front end, we also introduce uncertainty and instability within our provider networks on the back end as well. We do the retroactive take backs under the auspices of "ensuring the care was medically reasonable and necessary", even though that's also the rationale we use on the front end when our case managers ration your care in real time. So sign up now before this "Advantage" plan is full. As a special bonus, and only because we care so much about you, you'll be given the opportunity to experience outrageously high co-pays for pretty much everything - yes, even the stuff traditional Medicare provides with nothing out of pocket!" And for some reason, this abhorrent behavior is allowed to continue. Are the "Advantage" plans paying our less in benefits relative to traditional Medicare plans? Without question they are. But at what human cost? Does the answer to long term Medicare solubility rest in deceiving our most vulnerable citizens, creating barriers to the care they need, rationing the care they can receive, then taking aggressive punitive action, real or contrived, against the providers that did their best to provide them with the quality of life and dignity they morally (and legally) deserve? If the answer is truly yes, then God help us all.

      Posted by Rich Klemmer on 4/20/2018 11:42 AM

    • My outpatient clinic is not accepting insurance plans that use 3rd party administrators due to increasing administrative costs, too many unnecessary interruptions to care, unfair to patients who are typically denied access to fully complete the rehab process, and its more detrimental than beneficial. Check out Yelp's listing on ASH. We all need to make a stand against these policies.

      Posted by Sharlynn Landers, PT on 4/20/2018 12:20 PM

    • My experience to date support the above comments. I can’t be only Medicare/BCBS MI to have PT visits denied multiple times for upper humerus break. Just at point, 8 wks post injury where I can start more difficult, more meaningful therapy & may lose benefits. The eviCore process is time consuming & confusing & most likely not cost effective.

      Posted by Susan Sardelli on 9/2/2019 10:31 AM

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