Time has come for CMS to pare down prior authorizations: AMGA

© AliFuat - stock.adobe.com

There’s a new administration in Washington, D.C., but an old problem delaying health care around the nation — prior authorizations (PAs), especially for Medicare Advantage beneficiaries.

The U.S. Centers for Medicare & Medicaid Services (CMS) is considering the proposed rule for 2026 for Medicare Advantage and Medicare Part D. In that rule, physicians and other health care providers would be required to collect more data about a problem that’s already well known. Instead, it would be beneficial to eliminate, when possible, prior authorization requirements for medicines and procedures, according to AMGA, the American Medical Group Association.

“Over the past few years of rulemaking, CMS has moved to collect more information and data on how prior authorization affects patients, particularly those with social risk factors,” AMGA President and CEO Jerry Penso, MD, MBA, said in a news release. “This data will be useful, but it’s going to confirm what AMGA members already know. Prior authorization creates a barrier to care, and those who are least able to navigate an appeals process will be impacted the most.”

AMGA published its comments on the CMS rules relating to prior authorizations and other provisions such as behavioral health, artificial intelligence (AI) technology and the GLP-1 RA antidiabetes and antiobesity medications. AMGA Senior Director for Regulatory Affairs Darryl Drevna, MA, spoke with Medical Economics about the rules, how they could affect AMGA members, and the association’s stance on them. This transcript has been edited for length and clarity.

Medical Economics: Can you explain the nuances about social risk factors and prior authorization? Why is the comparison important between enrollees with specified social risk factors and those without?

Darryl Drevna, MA
_{© AMGA}

Darryl Drevna, MA: What CMS is looking to do is revise and strengthen protections for those who have maybe the most difficulty in accessing care. Those facing barriers such as transportation issues, food insecurity issues, are these patients at risk of having their utilities shut off because they can't afford them? What this rule is proposing is, as plans go through their utilization management procedures and policies, they want data on the types of patients that those how by authorization is directly influenced or affecting those patients ability to get care. Once the plans report data on these patients, they can have an idea of how prior authorization is affecting their ability to get the care they need. That's the genesis behind this rule. Now, what AMGA is arguing is, I don't think I need to look into a crystal ball or have a double-blind peer-reviewed study to know that those who have difficulty accessing care now are going to be the most harmed by prior authorization policies. I think anyone who's dealt with prior authorization knows it can be, at a minimum, incredibly inconvenient, even for those with the experience and the time and the resources to navigate that system. And now we're talking about patients who might not have that level of sophistication or the time or the ability to make those phone calls, work the system, and eventually get the care approved. I think it's laudable, and definitely appreciate that CMS wants to look into this, but I think we all know how this is going to end.

Medical Economics: AMGA’s letter stated, “We believe eliminating prior authorization rather than adding additional measures or evaluations would better service patients and providers while also addressing health equity concerns.” Why would that?

Darryl Drevna, MA: We definitely appreciate CMS’ concern and desire to address those health equity concerns. But what our providers, what our members have been saying — we had a regional meeting just last week, and prior authorization is the biggest pain point, I think, right now for our providers who have Medicare Advantage contracts. It is slowing down their ability to deliver the care they need at the right time. It is denying care claims for care that's already provided. If there's one thing that I'm hearing from my members over and over again, it's, we need to be reimbursed, we need to be paid for the care that we're providing, and prior authorization is, frankly, it's a roadblock for their ability to do that. So that's why AMGA has taken the position it has. Our language is pretty strong in this area. We really need to take a hard look at how prior authorization is being used, and where we can, it should be eliminated. You look at all the number of claims that eventually get paid on appeal, it's 90%, it's way up there. So, these claims are eventually are getting approved, this care eventually is getting authorized. It's just creating a bunch of obstacles and roadblocks between point A and point B.

Medical Economics: What are the means for ensuring equitable access to behavioral health services?

Darryl Drevna, MA: One of the things that AMGA members have told us as it relates to chronic disease or behavioral health concerns is, co-insurance or cost sharing, creates a significant barrier to access for those patients. Because someone is in a mental health crisis and they've got financial difficulties, you know, co-insurance, cost sharing, can be a real barrier. So what CMS is doing here is making sure that, MA plans don't charge more than they would under, traditional Medicare. It's sort of making sure that regardless of how a beneficiary is accessing their Medicare benefits, they're being treated equitably. And from AMGA’s perspective, anything that helps a patient get the care they need is something we're going to be supportive of.

Medical Economics: AI has become a new tool relating to many different aspects of health care and business. How could AI benefit Medicare Advantage? And what are potential pitfalls for using AI in evaluating patients?

Darryl Drevna, MA: This is still a very much developing technology here, and I think we're very excited about the use of AI. One of the benefits could be is, can you create an algorithm, can you create a program to help identify those patients who are at risk of either falling through the cracks or are off their medications or need to come in for a screening? Where are those areas that the computer can flag for a care manager or physician or for someone on that care team to reach out to that patient and see like, OK, we need you to come in to get your blood sugar screen, we need you to come in for a mammogram. Those type of things AI can do be wonderful to help leverage that technology to make sure we're reaching the patients, we're targeting our resources and time and energy to those patients who really need it. Now, the rub is — obviously this is way outside my area of expertise — how do you design these things so there's not some sort of glitch in the matrix, so to speak, so you're not missing a patient? Or it's making a mistake, and all of a sudden, instead of reaching out to those patients, it's ignoring those patients. This is still developing, and I’m pleased to see CMS is cognizant of the big benefit this could be. But there's some dangers there as well.

Medical Economics: Another technology that has expanded in recent years has been antidiabetes and antiobesity medications. CMS has proposed a reinterpretation of coverage for those. Why does AMGA support that?

Darryl Drevna, MA: CMS is reinterpreting the statute to get around a prohibition on Medicare coverage for weight loss medications. What they're doing here is classifying obesity as a chronic disease, and therefore it can be treated with these medications. This I think makes total sense. From our perspective, AMGA recognizes the importance of treating chronic disease and having a relationship with those patients and using any available tool in your arsenal, so to speak, to help those patients have the best possible outcome. Recognizing obesity as a chronic disease, I think is long overdue. I mean, it's been recognized by the American Medical Association and different specialty societies for a long time as a chronic disease. So I think this makes a lot of sense. Hopefully, this improves access to care for those patients, so they get the medications they need.

Medical Economics: We covered some of the main points that were in AMGA’s comments. What did I not ask about that you want our readers and viewers to know?

Darryl Drevna, MA: Medicare Advantage, we're all very aware that is more than 50% of the program, so it's critical that we get this program right, because beneficiaries are continuing to enroll. And it's a popular program, and it's popular for a reason with beneficiaries, with the supplemental benefits they provide. It's much easier in a lot of ways, one stop shopping. You've got part A, B and your drug benefit all enrolled in one, very much appreciated that that can be easier and a lot more convenient for patients. On the flip side, we've got to make sure it works for the providers who are working with those plans, so it adequately and appropriately reimburses for the care that's being delivered and doesn't throw up needless obstacles and roadblocks to ensuring it remains viable both for providers and patients.