Dear Administrator Verma:
As you and your staff work to reduce barriers to patient care through your Patients over
Paperwork initiative, we are writing to request that you improve how prior authorization (PA)
works under Medicare Advantage (MA). We are concerned that patients may be encountering
barriers to timely access to care that are caused by onerous and often unnecessary prior
authorization requirements. Therefore, we request your agency provide guidance to MA plans
regarding the use of prior authorization to ensure that these requirements do not create
inappropriate barriers to care for Medicare patients.
We recognize the important role that MA plays in the Medicare program and understand that
utilization review tools such as PA can sometimes play a role in ensuring patients receive
clinically appropriate treatment while controlling costs. However, we hear from physicians and
other health care providers in our districts about the growing administrative burdens associated
with PA requirements. Because MA plans are ultimately required to provide equivalent coverage
to fee-for-service (FFS) Medicare, which generally does not require pre-approval for services,
plans are precluded from using PA to inhibit access to services.
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. 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. We request you issue guidance to MA plans dissuading practices such as these and provide
direction to increase transparency, streamline PA, and minimize the impact on patients.
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Read full letter here
