The Medical Group Management Association (MGMA) submitted comments to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure in response to a CMS proposed rule that would revise the Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), Medicare cost plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations to implement changes related to Star Ratings, medication therapy management, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, passive enrollment, network adequacy, identification of overpayments, formulary changes, and other programmatic areas.
In the letter, MGMA asked CMS to take several steps, including:
- Finalize many of the prior authorization proposals included in the rules, saying that prior authorization tends to be 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 rulemaking, including eliminating step therapy, requiring gold-carding programs, and exempting medical groups that participate in value-based models from prior authorization requirements.
Prior Authorization Reform
MGMA reiterated its position that prior authorization reform is a “longstanding priority” for MGMA as 88% of medical groups report that prior authorization is “very or extremely burdensome.” The Association also referenced a 2022 HHS OIG report which found that 13% of prior authorization requests that were denied by MA plans actually met Medicare coverage rules and 18% of payment request denials met Medicare and MA billing rules.
MGMA noted that while CMS concurred with all three recommendations made by HHS OIG at the conclusion of that report, some of the Agency’s plans seem to be misaligned. One such example is that while CMS intends to discourage prior authorization from being a tool to discourage care, MGMA notes that prior authorization is not “necessary to confirm diagnoses and therefore, MGMA opposes CMS’ proposal which calls for this,” instead stating that CMS needs to establish guardrails to prevent high volumes of prior authorization requests by MA plans.
MGMA also notes that CMS should allow for MA beneficiaries to have access to the same items and services they would under Traditional Medicare and if applicable coverage rules do not exist under Traditional Medicare, the plan should use current evidence from widely used treatment guidelines or clinical literature. CMS should also ensure the definition of “clinical literature” meets the highest standard.
Additionally, MGMA notes, prior authorization approvals for MA plans must “remain valid for the duration of the approved course of treatment,” including a “minimum 90-day transition period for any active course of treatment after starting a course of treatment.”
MGMA also notes that without proper oversight, it is possible that the prior authorization policies will not be properly implemented, and therefore, the Association suggests that CMS “establish a portal for patients and providers to alert CMS to instances of health noncompliance.”
As far as the suggested electronic prior authorization program, MGMA supports the proposal, but with a “slight” change – shorten the timeframes that health plans have to respond to medical groups for prior authorization requests – CMS proposed 72 hours for an urgent prior authorization request and 7 days for “standard” requests.
Additional Suggestions
In addition to the proposed rule by CMS, MGMA took the opportunity to make additional suggestions that would help build upon prior authorization reforms, including eliminating step therapy (particularly that CMS reinstate the step therapy prohibition in MA plans for Part B drugs) and requiring MA plans to develop gold carding programs that would exempt providers from prior authorization requirements for certain services if they reach a certain approval rating over a period of time.