The Federation of American Hospitals is asking CMS to include how often Medicare Advantage carriers uphold or overturn initially denied prior authorization requests into how the agency calculates star ratings for the program.
In a document shared with Becker's Dec. 15, the federation outlined its full proposal to the agency. The association of taxpaying hospitals asked CMS to add a star ratings quality measure focused on the percentage of initial Medicare Advantage prior authorization denials that are upheld or overturned.
"The addition of this measure will enhance CMS's oversight of MA plans' denial of prior authorization and payments and provide beneficiaries with needed insight to inform their decision-making," the FAH wrote.
CMS star ratings score plans on clinical quality outcomes and member satisfaction. Plans must score four stars or higher to receive bonus payments from CMS.
In 2021, around 80% of prior authorization appeals were eventually approved in Medicare Advantage, according to the Medicare Payment and Advisory Commission.
"Given the extent to which denials are overturned, it is evident that insurers are intentionally using practices that slow the system down or enable them to avoid payment for necessary care," the FAH wrote.
Prior authorization in Medicare Advantage is facing increasing scrutiny from regulators and lawmakers. In November, 30 U.S. representatives urged CMS to require MA plans to report more prior authorization data.
Some hospitals have dropped Medicare Advantage contracts altogether in 2023. The most common reasons hospitals cite for breaking with Medicare Advantage are excessive prior authorization denial rates and slow payments from insurers.