The Centers for Medicare and Medicaid Services (CMS) have finalized their policies on prior authorization processes in the 2024 Medicare Advantage (MA) and Part D Final Rules. Providers have been supporting for the earlier authorization reform for years, as it creates significant burdens for them. The final rule aims to streamline the prior authorization process and ensure beneficiaries have consistent access to medically necessary care while maintaining utilization management tools. Healthcare experts agree that the further authorization rule is a big win for providers and will help reduce administrative burden and align Medicare Advantage regulations with traditional Medicare.
The Centers for Medicare and Medicaid Services (CMS) announced the 2024 Medicare Advantage (MA) and Part D Final Rules, which also contained rules and regulations on prior authorization procedures, prescription drug use, and marketing control. Providers and other healthcare stakeholders have been advocating for prior authorization reform for years, as prior authorization requirements create significant burdens for providers. According to data from the American Medical Association (AMA), physicians complete an average of 41 prior authorizations each week and spend an average of two business days on the processes. What’s more, 93 percent of physicians reported that patients face delays in accessing necessary care while waiting for health plans to authorize treatment or services.
Providers have been calling for prior authorization reform in the Medicare Advantage program. Provider organizations like the AMA and others have praised the revised regulations, saying that the CMS has made significant strides in the direction of resizing the prior authorization process. The final rule aims to ensure beneficiaries have consistent access to medically necessary care while maintaining utilization management tools and their role in the Medicare Advantage program. The policies will help reduce the administrative burden and align Medicare Advantage regulations with those under traditional Medicare.
The final rule clarified clinical criteria guidelines to ensure Medicare Advantage beneficiaries have access to the same care they would receive under traditional Medicare. The rule finalized requirements that aim to streamline the prior authorization process, stating that health plans can only use prior authorization to confirm the presence of a diagnosis or other medical criteria and ensure that an item or service is medically necessary. The rule also directed coordinated care plans to provide a minimum 90-day transition period when a beneficiary undergoing treatment switches to a new Medicare Advantage plan, during which the new plan cannot require prior authorization for the active treatment.
The final rule required all Medicare Advantage plans to review their utilization management policies annually and ensure they align with coverage guidelines under traditional Medicare. Additionally, prior authorization approvals for a course of treatment must remain valid for as long as medically necessary to avoid care disruptions in accordance with applicable coverage criteria, the patient’s medical history, and the provider’s recommendation. Healthcare experts agree that the prior authorization rule is a big win for providers, as the policies will help reduce administrative burden and align Medicare Advantage regulations with those under traditional Medicare.
The policies in the final rule do not take effect until January 1, 2024. However, some health plans have already limited their use of the process in the aftermath of various studies on prior authorization, including a report from the HHS Office of Inspector General. Providers can help themselves by making sure they’re familiar with the plan’s prior authorization requirements, so they know when a prior authorization is required and what the criteria are for meeting that prior authorization requirement to facilitate compliance. Additionally, increased adoption of gold carding by health plans could help incentivize provider compliance.
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