CMS Administrator Mehmet Oz, MD, discussed some of the biggest issues facing the Medicare Advantage program at an Oct. 15 industry conference. During his first six months on the job, CMS has already overseen policy moves to streamline prior authorization processes, expand fraud oversight, and improve home health assessments.
At the Better Medicare Alliance’s MA Leadership and Policy Forum, Dr. Oz shared his overarching belief that improving MA means ensuring that the cost of providing high-quality care does not exceed the cost of fee-for-service Medicare.
“The goal of having the highest quality care for the price we pay for fee-for-service is achievable,” he said. “If we reward insurers that improve outcomes at the fee-for-service price, there’s opportunity.”
“MA is still in its infancy. It’s walking, but can it run? Can it fly?” he asked, noting that MA is still evolving and can offer a unique opportunity for transformation of the healthcare system.
A major pain point, however, is the complexity and delays associated with prior authorization. The issue has been widely reported by health systems and physicians as a source of administrative burden that contributes to burnout, patient frustration, and delayed reimbursement.
“The most important thing is speed. It’s infuriating to be anxious about an illness while waiting for someone not directly involved in your care to approve what’s appropriate,” Dr. Oz said.
Echoing recent commitments from health insurers, he noted CMS’ push to streamline prior authorization processes and make them more efficient. In June, nearly 50 insurers said they would implement a standardized submission process for electronic prior authorizations, with the goal to be operational and available to plans and providers by January 1, 2027. The industry is aiming for at least 80% of electronic prior authorization approvals to be provided in real-time in 2027.
In 2024, CMS also finalized a rule to streamline the prior authorization process. Beginning primarily in 2026, certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.
“Do we need prior auth at all? I think we do, but done the right way,” Dr. Oz said. “We expect great things from this industry. When we see coasting or not pushing available technology, that’s a wasted opportunity.”
In his remarks, Dr. Oz also addressed the issue of fraud and abuse within Medicare Advantage.
“If you don’t police the system, you signal that bad apples might get away with things, and bad apples have lower costs because they don’t invest in quality,” he said. “Coming from the private sector with a limited window, I’m focused on cleaning up the neighborhood now by letting high-quality folks practice with appropriate reimbursement and allowing the system to flourish with people earnestly trying their best, not those taking advantage.”
The comments come amid a broader push from CMS to step up oversight of MA insurers, with the goal of auditing every MA plan annually. The increased scrutiny follows years of reports and Justice Department settlements regarding upcoding and other forms of program fraud, with some insurers inflating diagnoses to receive higher reimbursements.
“I built my career on preventive health and strongly support home visits. I do not support coding that doesn’t get treated or isn’t a focus of treatment,” Dr. Oz said. “You shouldn’t be dependent on coding; it shouldn’t matter that much. If coding adds benefit, you professionalize it, but don’t let it drive care without translating into changes.”
