MGMA issues guide to CMS for rule changes for prior authorizations

It is time for federal regulators to reform the prior authorization process for health care services, according to the Medical Group Management Association (MGMA).

The U.S. Centers for Medicare & Medicaid Services (CMS) is taking public comments on proposed rules to change the prior authorization process for Medicare Advantage plans starting in January 2026. New rules could lead to an estimated savings of $15 billion for physician practices and hospitals over 10 years, according to CMS.

Apart from possible financial benefits, those changes can’t come soon enough because prior authorizations are causing paperwork headaches for physicians and medical staff, while delaying care for patients. The problem was a burden for medical groups in 2021 and is getting worse, according to MGMA, citing membership poll data from last year.

“Physician groups point to delays in prior authorization decisions, resubmission of prior authorization, inconsistent payer payment policies, issues with peer-to-peer authorizations, unsustainable prior authorization volumes, and prior authorizations for routinely approved items and services as some of the most challenging aspects of prior authorization,” said the Feb. 10 letter from Anders Gilberg, MGMA senior vice president for government affairs, to CMS Administrator Chiquita Brooks-LaSure.

What’s needed

• “Appropriate use of prior authorization.” MGMA agreed with CMS that prior authorization should not be a tool to discourage care. But prior authorization is not necessary to confirm diagnoses and MGMA opposes CMS’ proposal for that. “CMS must establish guardrails to prevent high volumes of prior authorization requests by MA plans,” the letter said.
• Because MA beneficiaries must have access to the same items and services as those in Traditional Medicare, MA plans should publish evidence and explain rationales for internal coverage criteria in a prompt and timely manner. Doing so would ensure equitable access to items and services, and transparency.
• Prior authorizations should remain valid for the duration of ordered courses of treatment.
• MA plans must form a Utilization Management Committee to review clinical coverage criteria. Committees need at least one member with expertise in medical use or needs for items or services. The committees should represent the health care provider community and have more than one member independent of MA plans.
• Policies about clinical validity and transparency of coverage should extend to prescription drugs.
• CMS needs an oversight plan to enforce new policies.

More recommendations

• MGMA suggested additional reforms CMS should consider to help physicians and other health care providers.
• Eliminate step therapy or “fail first” treatment in which patients must try and fail certain treatments before moving on to others that may be more appropriate and more expensive.
• “Gold-carding” programs that waive prior authorization rules for certain services for providers who reach a particular approval rating over time. That method has worked in at least two states, Texas and West Virginia.
• Waive prior authorization rules for providers using value-based care models that already are incentivized to control costs while delivering high-quality care.

More information

CMS has published at least 25 public comments so far on the proposed rule changes. CMS announced the rule changes in December 2022 and has an information sheet about the proposals. There also is an official Federal Register notice with instructions on how to submit comments.