Radiologists are among nearly 120 physician groups urging the Centers for Medicare & Medicaid Services to fix a payment policy they say is hindering patient care.
Docs voiced their concerns in a Monday, Feb. 13, letter to CMS Administrator Chiquita Brooks-LaSure. Groups including the American Society of Neuroradiology and Society of Interventional Radiology thanked the agency for recently proposed actions to reform Medicare Advantage’s use of prior authorization, urging the feds to adopt the moves as quickly as possible.
Insurance companies deploy this tactic to determine if a product or service should be covered, hoping to avoid unnecessary healthcare spending. However, radiologists and other physicians say payers frequently abuse this tool.
“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” Jack Resneck Jr., MD, president of the American Medical Association, which also signed the letter, said in a statement. “We stand ready to continue our work with federal officials to remove obstacles and burdens that interfere with patient care.”
Backing their claims, the doc groups cited an April 2022 HHS investigation of prior authorization use. It found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments.
Examples of healthcare services involved in such denials included MRIs and other advanced imaging services, along with stays in post-acute facilities, the HHS Office of Inspector General wrote at the time.
More than 9 out of 10 physicians have reported delays while waiting for insurers to authorize necessary care, the AMA found in a recent survey.
CMS first announced its proposed Medicare Advantage changes on Feb. 1 and is accepting comments through March 3. The doc groups urged the agency to move quickly with any updates to provide relief to patients and providers. Remedies should include only using prior authorization to confirm diagnoses or other medical criteria and not to “delay or discourage care,” the societies wrote.
Medicare Advantage beneficiaries also should have access to the same services as they would under traditional Medicare. And these plans must not deny care ordered by a physician based on the particular provider type or setting, “unless medical necessity criteria are not met,” they added.
“We urge CMS to finalize these important changes for [Medicare Advantage] and Part D plans and look forward to continuing to work with you to reduce the burden of [prior authorization] as it relates to all care in all health insurance markets,” the letter concluded.
Radiologists face the heaviest burden from prior authorization, behind only radiation oncology and cardiology, a recent JAMA Health Forum analysis found.
Others signing the letter included the American College of Cardiology, American Society of Nuclear Cardiology, American College of Radiation Oncology and the American Society for Radiation Oncology.
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.