Prior Auth Reforms for Medicare Advantage, Work to Be Done With Private Insurers

Being a physician in the District in the 21st century means being on the front line of the most pressing public health issues in the world. In our small geographic boundaries, physicians help address issue found in every state all in one area. The issues are too lengthy to list on one webpage but physicians are on the front lines of addressing health issues for all District residents.

News, Statements, and Testimony on Health Equity Issues

25th Council session information coming soon.

Prior Auth Reforms for Medicare Advantage, Work to Be Done With Private Insurers

Apr 6, 2023, 10:46 AM by MSDC Staff

CMS rule changes for Medicare Advantage will help physicians and patients with more manageable prior auth requirements.

On April 5, CMS released a final rule on Medicare Parts C and D that, among other changes, reformed the program's prior authorization process.

This is a great win for physicians and practices who see Medicare patients, but does not impact the private insurance market. That is where B25-124 comes in, and what MSDC is working on before a May 24 hearing.

The final rule seems to incorporate provisions supported by the American Medical Association and MSDC, including:

Only using prior auths to confirm diagnoses to ensure medical necessity of services.
Establishing a Utilization Management Committee to review clinical coverage criteria
Allowing prior auth approvals to be valid throughout duration of treatment

These changes plus announcements by some insurers to voluntarily reduce prior auth requests seem to suggest progress in prior auth reform. Physicians, however, must put in place permanent changes now for all patients to ensure this progress.

The Committee on Health is having a hearing on comprehensive reform legislation on May 24. Visit msdc.org/priorauth to learn how you can make a difference for your patients.

Sample of Health Equity Legislation MSDC Tracked

Student Access to Treatment Amendment Act (B23-467)

What does it say? The bill allows for the administration of medicinal marijuana in schools as well as allows students to bring sunscreen to schools and apply it without a prescription.

MSDC position: MSDC supports the language permitting sunscreen application in schools

Current status: A win for DC physicians and public health! The legislation passed the Council in February and was signed by the Mayor. Previous temporary and emergency legislation permitted students to use sunscreen at schools this school year already.

Electronic Medical Order for Scope of Treatment Registry Amendment Act (B23-261)

What does it say? The bill requires DC Health to establish an electronic Medical Order for Scope of Treatment registry (eMOST).

MSDC position: MSDC supports this legislation to more easily allow patients to make their treatment orders known.

Current status: A win for the physician community and our patients! The Council passed the bill in December and the Mayor signed it into law on January 16, 2020.

Healthy Beverage Choices Amendment Act (B23-495)

What does it say? The bill would implement a 1.5 cent per ounce tax on the distribution of "sugary" beverages. The money collected from the tax would establish a Healthy People, Healthy Places Open Spaces Grant Program.

MSDC position: MSDC sent a letter to Council Chair Mendelson asking for a hearing to discuss all of the issues around a beverage tax.

Current status: The bill was introduced October 8, 2019 and referred to the Committee on Business and Economic Development and the Committee of the Whole.