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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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