The American Hospital Association (AHA) issued a letter on March 7 to the Centers for Medicare & Medicaid Services (CMS), urging the agency to join with Congress in requiring Medicare Advantage plans to waive prior authorization and other policies in the midst of public health emergencies. CMS previously requested information regarding prior authorization requirements for patients transferring to post-acute care from the hospital setting, as well as recommendations for other health plan utilization services, including behavioral care referrals.
“While the flexibilities CMS offered for [Medicare Advantage] plans to relax or waive prior authorization requirements during the pandemic were critical for many hospitals and health systems in aiding the COVID-19 response, a substantial limitation of this flexibility is that it encouraged, but did not mandate, that plans waive such processes,” Stacey Hughes, executive vice president of the AHA, wrote in the letter. “While many plans worked collaboratively with provider partners to waive or relax onerous prior authorization requirements during the [public health emergency], others did not, or only did so during the initial stages. The continued use of prior authorization and other health plan utilization management policies by some plans throughout the pandemic exacerbated capacity issues, caused delays affecting patient care and resulted in high rates of inappropriate denials.”
The AHA called for greater oversight into the execution of Medicare Advantage plans to ensure continuity of care that is beneficial to patients, payers and providers alike. They also noted that seamless transitions from the general care setting to post-acute care are necessary to keep hospitals from becoming overwhelmed, especially within the context of a public health emergency. Inconsistent guidelines and application have led to situations in which hospitals are overburdened by restrictions to acute care access.
“We recognize that prior authorization is a tool that, when used appropriately, can help align patients’ care with their health plan benefit structure and facilitate compliance with clinical best practices,” Hughes wrote. “However, its misuse and application during a [public health emergency] has negatively affected patient care and the delivery system’s response to a global health crisis.”
The AHA letter also cited a lack of transparency among prior authorization guidelines, as well as an investigation by the Office of the Inspector General, which contended that unwarranted denials were commonplace. Between 2014 and 2016, for example, Medicare Advantage overturned approximately 75 percent of prior authorization and coverage denials through its own appeals process, representing approximately 216,000 denials per year.
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