Medical Societies Unite in Support of Proposed Prior Authorization Reforms

Washington, DC 20201

Dear Administrator Brooks-LaSure:

On behalf of the undersigned organizations representing physicians across the country, we thank you for listening to our concerns, as well as those of our patients, and proposing meaningful prior authorization (PA) reforms in the Centers for Medicare & Medicaid Services' (CMS’) Notice of Proposed Rule Making for Part C & Part D (CMS–4201–P) (“proposed rule”) that will increase access to medically necessary care.

Recent American Medical Association (AMA) survey data show that 93 percent of physicians report care delays or disruptions associated with PA. AMA data also show that 34 percent of physicians report that PA has led to a serious adverse event (e.g., hospitalization, permanent impairment, or even death) for a patient in their care and that 91 percent of physicians see PA as having a negative effect on their patients’ clinical outcomes. Moreover, the Office of Inspector General (OIG) 2022 report found that 13 percent of PA requests denied by Medicare Advantage (MA) plans met Medicare coverage rules, and 18 percent of payment request denials met Medicare and MA billing rules. We applaud CMS’ proposed policy responses to the findings of the OIG’s report and to ongoing stakeholder concerns and urge CMS to finalize these policies to help protect beneficiaries’ access to medically necessary care.

Clinical validity and transparency of coverage criteria

Physicians want nothing more than to provide clinically appropriate care to their patients. We urge CMS to finalize the following provisions to improve the coverage criteria used in medical necessity determinations, ensure a clinically sound foundation for PA programs, and protect access to care:

Continuity of care and reliance on approvals

Repetitive PA requirements or approval revocations can disrupt care and lead to adverse clinical outcomes—particularly for patients with chronic conditions. CMS should finalize the policy proposals below to protect patients from care interruptions, treatment delays, and unanticipated medical costs:

Alternatives and Exemptions

According to the AMA’s PA survey, physicians and their staff spend an average of two business days per week completing the PA workload for a single physician, and 88 percent of physicians describe their PA burden as high or extremely high. This translates to less time with patients and contributes to an exhausted and overwhelmed workforce, underscoring the need to reduce overall PA volume. We are pleased that CMS is encouraging MA plans to implement gold-carding programs to exempt physicians with high approval rates from PA requirements. Our organizations stand ready to work with CMS to develop meaningful guidelines for gold-carding programs that would reduce the volume of PAs to the benefit of all stakeholders, and we encourage CMS to establish a requirement on MA plans to develop such programs.

Automation and efficiency
Tasks related to PA—from initial coverage requirement discovery to documentation submission—remain largely unautomated. We therefore support the proposed rule’s requirement that Part D plans implement the National Council for Prescription Drug Programs Real Time Prescription Benefit standard. This would allow physicians to check PA requirements and drug formulary status at the point of prescribing in EHRs and support informed conversations with patients about therapy costs.
Program enhancements

We appreciate CMS’ efforts to holistically reform PA programs and stress the need to continue evaluation of MA and Part D programs for more opportunities to improve the PA process. We note that Part D beneficiaries would benefit from the clinical validity provisions in the proposed rule. We urge CMS to further strengthen its PA reform effort by extending its proposed clinical validity and transparency of coverage criteria polices into the area of prescription drugs.

Conclusion

Thank you for listening to our calls for PA reform and proposing policies that will help right-size these requirements that so often stand in the way of medically necessary care. We urge CMS to finalize these important changes for MA and Part D plans and look forward to continuing to work with you to reduce the burden of PA as it relates to all care in all health insurance markets.