Dear Administrator Verma:
The undersigned organizations are writing to urge the Centers for Medicare & Medicaid Services
(CMS) to provide guidance to Medicare Advantage (MA) plans on prior authorization (PA)
processes through its 2020 Call Letter. CMS’ guidance should direct plans to target PA
requirements where they are needed most. Specifically, CMS should require MA plans to
selectively apply PA requirements and provide examples of criteria to be used for such
programs, including, for example, ordering/prescribing patterns that align with evidencebased guidelines and historically high PA approval rates. At a time when CMS has
prioritized regulatory burden reduction in the patient-provider relationship through its Patients
Over Paperwork initiative, we believe such guidance will help promote safe, timely, and
affordable access to care for patients; enhance efficiency; and reduce administrative burden on
physician practices.
A Consensus Statement on Improving the Prior Authorization Process, issued by the AMA, the
American Hospital Association, America’s Health Insurance Plans, the American Pharmacists
Association, Blue Cross Blue Shield Association, and the Medical Group Management
Association in January 2018, identified opportunities to improve the prior authorization process,
with the goals of promoting safe, timely, and affordable access to evidence-based care for
patients; enhancing efficiency; and reducing administrative burdens.1
It notes that the PA process
can be burdensome for all involved—health care providers, health plans, and patients—and that
plans should target PA requirements where they are needed most. Providers and health plans
agree that making policy changes that eliminate PA on services for which there is low variation
in care, promote greater transparency regarding which services are subject to PA, and protect
patients to ensure PA does not impact continuity of ongoing care are essential. We urge CMS
to require MA plans to follow the important concepts outlined in the Consensus Statement
to improve MA patients’ access to timely, medically necessary care.
…
Read full letter here
