“Specifically, some MA plans frequently apply more stringent medical necessity criteria than traditional Medicare, apply excessive prior authorization requirements, use inappropriate utilization management tools, and require onerous and duplicative clinical documentation submissions to substantiate the need for services,” the AHA said in a Sept. 14 news release.
The group supports the Medicare Advantage prior authorization reform bill that recently passed in the U.S. House of Representatives, but said it is urging Congress to do more to improve oversight.
It is asking Congress to:
1. Establish penalties on plans when prior authorization processes lead to care delays.
2. Increase CMS oversight and enforcement by increasing plan reporting on coverage denials, appeals and grievances; making plan performance data publicly available; and conducting targeted audits based on plan performance.
3. Create a process to submit complaints to CMS.
4. Align medically necessary criteria across Medicare Advantage and traditional Medicare.
5. Expand network adequacy requirements for certain post-acute sites of care.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.