MGMA: Prior Authorization Reforms Require Enforcement Mechanism

Noting that prior authorization reform is one of its longstanding priorities, the Medical Group Management Association (MGMA) has responded to a Centers for Medicare & Medicaid Services’ (CMS’) Notice of Proposed Rule Making that will reform certain aspects of prior authorization.

With a membership of more than 60,000 medical practice administrators, executives, and leaders, MGMA represents more than 15,000 medical groups in which more than 350,000 physicians practice. These groups range from small private practices in rural areas to large regional and national health systems.

In its letter, MGMA urged CMS to:
• Finalize many of the prior authorization proposals in this rule that address our long- established concerns. Prior authorization is routinely the most burdensome issue facing medical group practices.
• Apply the proposed clinical validity and transparency of coverage criteria policies beyond the current scope to include prescription drugs.
• Establish and implement an oversight plan that will hold plans accountable for noncompliance.
• Include additional prior authorization reforms in future rulemaking, such as eliminating step therapy, requiring gold-carding programs, and exempting medical groups participating in value-based models from prior authorization requirements.

MGMA notes that despite feedback from group practices regarding the unnecessary administrative burden, cost, and delay of treatment associated with prior authorization requirements, 79 percent of MGMA members report that these requirements increased over the previous 12 months.

In addition to rising requirements, medical groups also report a lack of automation in payers’ prior authorization processes, slow responses from payers for approvals, and increased time spent by practice staff working to secure prior authorizations as challenges.

Here are a few of the recommendations MGMA made to CMS in support of its proposed rule:

• Appropriate use of prior authorization. CMS proposes that prior authorization processes for coordinated care plans must be limited to the use of only confirming the presence of diagnosis or other medical criteria that are the basis for coverage determinations to ensure basic benefits are medically necessary. “While we appreciate CMS’ intent to limit the negative consequences of prior authorization by limiting its use to confirming the presence of a diagnosis, the real-life impact of prior authorization is that it inherently delays patient care. Therefore, although we support CMS’ intent to discourage prior authorization from being a tool to discourage care, we do not believe that prior authorization is necessary to confirm diagnoses and therefore, MGMA opposes CMS’ proposal which calls for this. CMS must establish guardrails to prevent high volumes of prior authorization requests by MA plans. This can be done via gold-carding programs and value-based care arrangements.”

• Equitable access to items/services and transparency. MA beneficiaries must have access to the same items and services as they would under Traditional Medicare. If applicable coverage rules do not exist under Traditional Medicare, plans must use current evidence from widely used treatment guidelines or clinical literature for internal clinical coverage criteria, which must then be made publicly available. MGMA urges CMS to finalize this proposal and ensure the definition of “clinical literature” meets the highest standard. MGMA said it believes that MA plans should publish a publicly accessible summary of the evidence, a list of the sources of evidence, and an explanation of the rationale for the internal coverage criteria in a prompt and timely manner— transparency is critical in ensuring that MA plans are developing and using coverage criteria in a way that aligns with Traditional Medicare. This published information should be readily and easily accessible to group practices.

• Continuity of care. MGMA said MA plans’ prior authorization approvals must remain valid for the duration of the approved course of treatment. MA plans would have to provide a minimum 90-day transition period for any active course of treatment after starting a course of treatment. MGMA’s letter urges CMS to finalize this proposal and require that prior authorization be valid for the duration of the ordered course of treatment.

• Enforcement. MGMA notes that without the necessary enforcement mechanisms, its members are concerned that these policies will never be properly implemented. “We urge CMS to establish an oversight plan to enforce implementation of these new requirements. We suggest CMS establish a portal for patients and providers to alert CMS to instances of health plan noncompliance. Once these rules are finalized, we recommend CMS take steps to educate stakeholders as to make certain OIG’s findings do not continue.”

Among the policies that MGMA urged CMS to consider in future rule-making are:

• Gold-carding programs. An approach to exempting certain clinicians or items and services from prior authorization requirements is implementing a “gold-carding” program. Gold-carding programs exempt providers from prior authorization requirements for certain services if they reach a particular approval rating over a period of time, thereby allowing physician practices to divert resources towards patient care. States have embraced this approach — Texas and West Virginia have successfully passed gold-carding laws.

• Waive prior authorization requirements for providers who are participating in value-based models of care. MGMA claims that groups who are part of value-based care models are already incentivized to control costs and deliver high-quality care. The organization said it is unnecessary and a further impediment to delivering care to require these group practices to go through the motions of seeking prior authorization approvals when their costs are already controlled.