Prior Auth Reforms for Medicare Advantage, Work to Be Done With Private Insurers April 6, 2023
Written by MSDC Staff
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.