Calling the requirements "onerous and often unnecessary," more than 100 members of the US House of Representatives are pressing for improvements to the way prior authorization (PA) is used—and often misused—in Medicare Advantage (MA) plans. The lawmakers' call for changes echoes concerns voiced earlier this year by a coalition that includes APTA.
A bipartisan group of 103 legislators signed on to the October 10 letter to US Centers for Medicare and Medicaid Services (CMS) administrator Seema Verma, requesting that Verma direct the agency to conduct investigations around the use of prior authorization in MA, and to issue guidance "dissuading" MA plans from including requirements that include unnecessary barriers to care.
"It is our understanding that some plans require repetitive prior approvals for patients that are not based on evidence and may delay medically necessary care," the lawmakers write. "Many of these PA requirements are for services or procedures performed in accordance with an already-approved plan of care, as part of appropriate, ongoing therapy for chronic conditions, or for services with low PA denial rates."
The letter underscores the message delivered to Verma earlier this year by way of a letter from the Coalition to Preserve Rehabilitation (CPR), a group of 28 health provider, patient, and care professional and advocacy groups that includes APTA, 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, among others.
The CPR letter suggests that CMS take its cue from the private insurance industry, which has been moving away from prior authorization, or at least investigate 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."
The legislators' letter to Verma makes reference to the efforts of "key stakeholders"—presumably, CPR and other groups—and requests that "you and your staff engage with these organizations on additional opportunities to improve the PA process for all stakeholders."
APTA will continue to monitor this issue and share developments as they arise.