Ledes from the Land of Enchantment

Will CMS Crack Down on Prior Authorization?

There’s the Idaho doctor whose infant daughter developed a brain tumor. A woman in Southern California who waited months for an MRI before dying in the hospital. And a North Carolina patient who has trigeminal neuralgia — a condition so painful it’s commonly called the “suicide disease.”

They all have something in common, aside from a nightmare diagnosis. Their insurance companies, at some point, denied doctor-recommended care through a process called prior authorization — a set of rules, unique to every health insurance plan, requiring preapproval for some tests, procedures and prescriptions. Sometimes it’s called preauthorization; sometimes precertification. Regardless, prior authorization is almost universally despised by doctors and patients. 

In 2021, Medicare Advantage insurers processed an average of 1.5 prior authorization requests for every enrolled patient.

Legislation to regulate prior authorization for Advantage patients has strong support from lawmakers, but a bill hasn’t yet passed Congress. The Centers for Medicare & Medicaid Services is weighing a proposed rule that could help millions more — including anyone enrolled in Medicare Advantage, Medicaid or an Obamacare marketplace policy. 

The CMS rule, if implemented, would require some insurers to automate their prior authorization processes, respond to expedited prior authorization requests within 72 hours and standard requests within seven calendar days, and provide more information when they issue denials. 

But CMS closed the public comment period on the rule 10 months ago and has said nothing since then about when, or if, it will be finalized. “There are no updates at this time,” a CMS spokesperson told me last Friday.

The American Hospital Association issued a statement in October urging CMS to act quickly. Jesse Ehrenfeld, president of the American Medical Association, told KFF Health News on Monday that he hopes the proposed rule, if finalized, would “move the needle a little bit” — but he said it won’t be enough. 

I think we’re going to have to have regulatory relief from Congress,” said Ehrenfeld, an anesthesiologist. “Unfortunately, I hear from colleagues every week who are just at their wits’ end and it’s frustrating. I see it with my own parents.”

Insurers, he said, “continue to just harass patients, really, to improve their bottom line.” 

David Allen, a spokesperson for AHIP, the insurance industry’s main lobbying group, argued health insurers use prior authorization selectively to ensure “the right care is delivered at the right time in the right setting— and covered at a cost that patients can afford. That’s what prior authorization helps deliver.”

He added: “We make every effort to ease the burden on patients and providers.”

Meanwhile, patients across the country are stuck navigating a system rife with roadblocks, red tape and appeals.

“For them to take weeks — up to months — to provide an authorization is ridiculous,” said Marine Corps veteran Ron Winters, who blames the Department of Veterans Affairs for delaying his cancer treatment. “It doesn’t matter if it’s cancer or not.”

The proposed federal reforms wouldn’t apply to veterans such as Winters who receive their care through Veterans Affairs or the estimated 153 million Americans covered by private, employer-sponsored plans. 

Even so, in anticipation of new regulations, many insurers already have started updating prior authorization processes for their private plans.

“It’s not clear to me that CMS is ‘leading’ the way here, so to speak,” Robert Hartwig, director of the Center for Risk and Uncertainty Management at the Darla Moore School of Business at the University of South Carolina, said in an email. “I do think, however, that CMS sees that widespread adoption of electronic PA processes are on the near-horizon and is willing to use its heft as a major payer to expedite the transition.”


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