Viewpoint: How to improve prior authorization for Medicare Advantage

A trio of authors outlined proposed improvements to the prior authorization process for Medicare Advantage in an opinion piece published in JAMA Network Oct. 3. 

The piece was written by Kelly Anderson, PhD, an assistant professor at Aurora-based University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Michael Darden, PhD, an associate professor at Baltimore-based Johns Hopkins University's Carey School of Business; and Amit Jain, MD, chief of minimally invasive spine surgery at Johns Hopkins Medicine's Department of Orthopaedic Surgery. 

"If used effectively, prior authorization can serve as a powerful lever to improve appropriateness of care, reduce overuse, and contain burgeoning health care costs," the authors wrote. "However, misapplication can result in harms to patients and unnecessary care delays, which can be expensive in the mid-term and long-term, and further undermine patient and clinician confidence in the process."

The authors said to improve the prior authorization process, health insurers should use an electronic process with time-bound requirements for initial and appeals decisions. Insurers should also be mandated to report guidelines used to make prior authorization decisions and seek input from respective medical societies and stakeholder groups on an annual basis. 

They said those recommendations are consistent with legislation that is currently proposed in Congress. The House of Representatives passed a Medicare Advantage prior authorization reform bill in September, which is now receiving further consideration in the Senate. 

Expanding on that legislation, the authors said the relative benefits and costs of prior authorization should be reviewed by CMS at the procedure level. Medicare Advantage insurers should also report approval and denial rates annual to CMS based on beneficiary sociodemographic characteristics and by procedure type. This would allow CMS to monitor whether prior authorization policies may be increasing disparities in access to care. 

They also said CMS should audit the denials of the plans with high-denial rates. Thresholds for the audit could be based on a comparison with other Medicare Advantage plans as well as in consultation with patient, caregiver, clinician and payer stakeholders.

Read the full article here

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