CMS finalizes reforms to address prior authorization problem that has plagued radiology

The Centers for Medicare & Medicaid Services released a final rule Wednesday aimed at reforming prior authorization—a health insurer utilization management tactic that has plagued radiology and other specialties.

CMS said the changes will streamline prior authorization, reducing disruptions while preserving continuity of care for Medicare Advantage beneficiaries. The agency’s goal, in part, is to ensure that seniors on these plans have the same access to care they would under traditional Medicare.

“People with Medicare deserve to have access to accurate information when making coverage choices, and to be able to get the care they need without excessive burden or delays,” Meena Seshamani, MD, PhD, CMS deputy administrator and director of the Center for Medicare, said in a statement.

The final rule will require that, once a health plan grants prior authorization for a service, that approval will remain valid “for as long as medically necessary” to help patients avoid disruptions in care. It also will require Medicare Advantage plans to review their utilization management policies on an annual basis. Any denials based on medical necessity must be reviewed by healthcare professionals with relevant experience related to the service, prior to a plan issuing a denial, according to a CMS fact sheet.

“CMS has received numerous inquiries regarding the use of prior authorization by Medicare Advantage plans and the effect on beneficiary access to care,” the agency said. “In the rule, CMS finalizes impactful changes to address these concerns and to advance timely access to medically necessary care for enrollees.”

Prior to the announcement from CMS, commercial insurers has already started sharing their intent to reform prior authorization—a key area of contention for the AMA and other doc groups. About 94% of physicians surveyed recently said that prior authorization results in care delays, while 80% said it can at least sometimes lead to patients abandoning care.

Insurance giant UnitedHealthcare on March 29 said it plans to cut down on nearly 20% of current prior authorizations in a bid to “simplify the healthcare experience” for providers and patients. The reforms are expected to begin in Q3 of 2023 and touch beneficiaries in Medicare Advantage, commercial and Medicaid plans. UnitedHealthcare also said it will launch a new “national Gold Card Program” in early 2024 for provider groups who meet certain requirements, eliminating the preapproval process for most procedures.

“Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members,” Anne Docimo, MD, chief medical officer of UHC, said in a statement.

A spokesman said UnitedHealthcare plans to continue requiring prior authorization for procedures deemed investigational, experimental or unproven. Same for those that could potentially pose risk to patient safety. Examples would include heart valve replacement surgeries, knee and hip replacements, and therapies provided as part of clinical trials. Meanwhile, codes to be removed from its PA process will have a track record of adhering to evidence-based guidelines. Orthopedic support devices and genetic tests used for making diagnoses are just a few examples, UnitedHealthcare spokesman Matthew Rodriguez told Radiology Business.

AMA President Dr. Jack Resneck Jr., MD, said he is “cautiously optimistic” about the reforms announced by UnitedHealthcare. However, the association is still awaiting further details to confirm that providers will see meaningful improvement.

“Reducing the volume of prior authorization demands and implementing gold-carding programs are both central reforms we have sought,” he said by email on March 29, prior to the CMS announcement. “We strongly urge other members of the health insurance industry to reduce the overall volume of prior authorization requirements and streamline the process to ensure timely patient access to medically necessary care.”

Radiologists face the heaviest burden from prior authorization, behind only radiation oncology and cardiology, a recent JAMA Health Forum analysis found. Asked to comment on the UnitedHealthcare announcement, the ACR said there is a clear need for change.

"The ACR feels strongly that alternatives to prior authorization—such as using physician-developed appropriate use criteria guidelines as part of an automated clinical decision support system, can be more effective, less intrusive, and a more efficient utilization-control tool,” the college said in a March 30 statement shared with Radiology Business. “EMR-embedded systems remove the need to hire employees specifically to navigate the laborious prior authorization maze in use today. The systems are widely used today, and all evidence shows their effectiveness in ordering the correct advanced imaging study in a matter of seconds with minimal disruption in clinicians’ time.”

Marty Stempniak

Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic. 

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