Physician organizations call for prior authorization changes

A host of physician organizations are calling on the Centers for Medicare and Medicaid Services (CMS) to pump the brakes on the expanded use of prior authorizations.

The letter is addressed to Elizabeth Richter, the acting administrator for CMS, and is signed by 40 organizations including the American Academy of Family Physicians, the American Medical Association, and the Center for Medicare Advocacy. It details the growing concern that the expanded use of prior authorizations is in opposition with Medicare’s traditional view of the practice of using the practice sparingly in the interest of patient access to care.

“In the calendar year (CY) 2020 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule (CMS-1717-FC), CMS established a nationwide prior authorization process for five hospital outpatient department (OPD) services that have cosmetic uses in addition to therapeutic indications, with an implementation date of July 1, 2020,” the letter says. “Then, just months after that implementation, CMS expanded prior authorization to two new service categories in the CY 2021 OPPS/ASC Final Rule (CMS-1736-FC)—Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators.”

The organizations believe this action was taken despite evidence Medicare Administrative Contractors sometimes failed to process prior authorization requests in the time mandated by the agency and that even CMS has acknowledged the lack of data to track the effectiveness of the issue, according to the letter.

The signers are calling for CMS to suspend the prior authorization requirements in general or for particular services through a notification on the CMS website. They also call on CMS to delay requirements for the two new service categories past July 1 and withhold action on further expansion of requirements until the agency has conducted a thorough investigation of the impact of prior authorizations for the five procedures implemented in July 2020 and until CMS establishes specific criteria to guide its prior authorization decision-making.