The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room
445–G 200 Independence Avenue, SW
Washington, DC
20201
Dear Administrator Brooks-LaSure:
On behalf of the undersigned organizations representing physicians across the country, we thank you for listening to our concerns, as well as those of our patients, and proposing meaningful prior authorization (PA) reforms in the Centers for Medicare
& Medicaid Services’ (CMS’) Notice of Proposed Rule Making for Part C & Part D (CMS–4201–P) (“proposed rule”) that will increase access to medically necessary care.
Recent American Medical Association (AMA) survey data show that 93 percent of physicians report care delays or disruptions
associated with PA. AMA data also show that 34 percent of physicians report that PA has led to a serious adverse event (e.g., hospitalization, permanent impairment, or even death) for a patient in their care and that 91 percent of physicians see PA
as having a negative effect on their patients’ clinical outcomes. Moreover, the Office of Inspector General (OIG) 2022 report found
that 13 percent of PA requests denied by Medicare Advantage (MA) plans met Medicare coverage rules, and 18 percent of payment request denials met Medicare and MA billing rules. We applaud CMS’ proposed policy responses to the findings of the OIG’s report and to ongoing stakeholder concerns and urge CMS to finalize these policies to help protect beneficiaries’ access to medically necessary care.
Clinical validity and transparency of coverage criteria
Physicians want nothing more than to provide clinically appropriate care to their patients. We urge CMS to finalize the following provisions to improve the coverage criteria used in medical necessity determinations, ensure a clinically sound foundation for PA programs, and protect access to care:
- MA plans may only use PA to confirm diagnoses or other medical criteria and ensure the medical necessity of services. In other words, PA is not a tool to be used to delay or discourage care.
- MA beneficiaries must have access to the same items and services as they would under Traditional Medicare. When no applicable coverage rule exists under Traditional Medicare, plans must use current evidence from widely used treatment guidelines or
clinical literature for internal clinical coverage criteria, which must then be made publicly available.
- MA plans must establish a Utilization Management Committee to review their clinical coverage criteria and ensure consistency with traditional Medicare guidelines.
- MA plans cannot deny care ordered by a contracted physician based on a particular provider type or setting unless medical necessity criteria are not met.
Continuity of care and reliance on approvals
Repetitive PA requirements or approval revocations can disrupt care and lead to adverse clinical outcomes—particularly for patients with chronic conditions. CMS should finalize the policy proposals below to protect patients from care interruptions, treatment delays, and unanticipated medical costs:
- MA plans’ PA approvals must remain valid for the duration of the course of treatment.
- MA plans must provide beneficiaries with a 90-day transition period where a PA would remain valid for any ongoing course of treatment when beneficiaries change plans or enter MA.
- After PA approval, MA plans cannot retroactively deny coverage for a lack of medical necessity.
Alternatives and Exemptions
According to the AMA’s PA survey, physicians and their staff spend an average of two business days per week completing the PA workload for a single physician,
and 88 percent of physicians describe their PA burden as high or extremely high. This translates to less time with patients and contributes to an exhausted and overwhelmed workforce, underscoring the need to reduce overall PA volume. We are pleased
that CMS is encouraging MA plans to implement gold-carding programs to exempt physicians with high approval rates from PA requirements. Our organizations stand ready to work with CMS to develop meaningful guidelines for gold-carding programs that would reduce the volume of PAs to the benefit of all stakeholders, and we encourage CMS to establish a requirement on MA plans to develop such programs.
Automation and efficiency
Tasks related to PA — from initial coverage requirement discovery to documentation submission — remain largely unautomated. We therefore support the proposed rule’s requirement that Part D plans implement the National Council for Prescription Drug Programs Real Time Prescription Benefit standard. This would allow physicians to check PA requirements and drug formulary status at the point of prescribing in EHRs and support informed conversations with patients about therapy costs.
Program enhancements
We appreciate CMS’ efforts to holistically reform PA programs and stress the need to continue evaluation of MA and Part D programs for more opportunities to improve the PA process. We note that Part D beneficiaries would benefit from the clinical validity
provisions in the proposed rule. We urge CMS to further strengthen its PA reform effort by extending its proposed clinical validity and transparency of coverage criteria polices into the area of prescription drugs.
Conclusion
Thank you for listening to our calls for PA reform and proposing policies that will help right-size these requirements that so often stand in the way of medically necessary care. We urge CMS to finalize these important changes for MA and Part D plans and look forward to continuing to work with you to reduce the burden of PA as it relates to all care in all health insurance markets.
Sincerely,
American Medical Association
AMDA - The Society for Post-Acute and Long-Term Care Medicine
American Academy of Allergy, Asthma & Immunology
American Academy of Dermatology Association
American Academy of Facial Plastic and Reconstructive
Surgery
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngic Allergy
American Academy of Otolaryngology
- Head and Neck Surgery
American Academy of Physical Medicine and Rehabilitation
American Academy of Sleep Medicine
American Association for Hand Surgery
American Association of Neurological Surgeons
American Association
of Neuromuscular & Electrodiagnostic Medicine
American Association of Public Health Physician
American Associations of Orthopaedic Surgeons
American College of Allergy, Asthma & Immunology
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Gastroenterology
American College of Lifestyle Medicine
American College of Medical Genetics and Genomics
American College
of Obstetricians and Gynecologists
American College of Osteopathic Internists
American College of Physicians
American College of Radiation Oncology
American College of Rheumatology
American College of Surgeons
American
Epilepsy Society
American Gastroenterological Association
American Geriatrics Society
American Orthopaedic Foot & Ankle Society
American Osteopathic Association
American Society for Clinical Pathology
American Society
for Dermatologic Surgery Association
American Society for Gastrointestinal Endoscopy
American Society for Laser Medicine and Surgery, Inc.
American Society for Radiation Oncology
American Society of Addiction Medicine
American Society of Anesthesiologists
American Society of Cataract & Refractive Surgery
American Society of Hematology
American Society of Interventional Pain Physicians
American Society of Neuroradiology
American Society of Nuclear Cardiology
American Society of Retina Specialists
American Society of Transplant Surgeons
American
Urological Association
American Vein & Lymphatic Society
American Venous Forum
Association for Clinical Oncology
Association of American Medical Colleges
College of American Pathologists
Congress of Neurological Surgeons
Endocrine Society
GLMA: Health Professionals Advancing LGBTQ+ Equality
Heart Rhythm Society
Medical Group Management Association
Outpatient Endovascular and Interventional Society
Society for Cardiovascular Magnetic
Resonance
Society for Vascular Surgery
Society of Cardiovascular Computed Tomography
Society of Critical Care Medicine
Society of Hospital Medicine
Society of Interventional Radiology
Society of Pediatric Dermatology
Society of Thoracic Surgeons
Spine Intervention Society
Medical Association of the State of Alabama
Alaska State Medical Association
Arizona Medical Association
Arkansas Medical Society
California Medical Association
Colorado Medical Society
Connecticut State Medical Society
Medical Society of Delaware
Medical Society of the District of Columbia
Medical Association of Georgia
Idaho Medical Association
Illinois State Medical
Society
Indiana State Medical Association
Iowa Medical Society
Kansas Medical Society
Kentucky Medical Association
Louisiana State Medical Society
Maine Medical Association
MedChi, The Maryland State Medical Society
Massachusetts Medical Society
Michigan State Medical Society
Minnesota Medical Association
Mississippi State Medical Association
Missouri State Medical Association
Montana Medical Association
Nebraska Medical
Association
Nevada State Medical Association
Medical Society of New Jersey
New Mexico Medical Society
Medical Society of the State of New York
North Carolina Medical Society
North Dakota Medical Association
Ohio State Medical Association
Oklahoma State Medical Association
Oregon Medical Association
Pennsylvania Medical Society
South Carolina Medical Association
South Dakota State Medical Association
Tennessee Medical
Association
Texas Medical Association
Utah Medical Association
Vermont Medical Society
Medical Society of Virginia
Virgin Island Medical Society
Washington State Medical Association
West Virginia State Medical Association
Wisconsin Medical Society
Wyoming Medical Society
View a PDF version of this letter here.
