Medical Societies Unite in Support of Proposed Prior Authorization Reforms

The Society, along with the American Medical Association (AMA) and 118 other leading medical societies, united in strong support of the meaningful prior authorization reforms proposed for Medicare Advantage and the Medicare prescription drug benefit. The physician organizations sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure thanking her and urging CMS to finalize proposed prior authorization reforms that target the inappropriate use of authorization requirements by Medicare Advantage plans to delay, deny, and disrupt the provision of medically necessary care to patients.

Reforms proposed by CMS must be implemented amid mounting evidence that Medicare Advantage plans are delaying or even preventing Medicare beneficiaries from getting optimal care, resulting in alarming effects on patient health.

• The most recent AMA survey found more than nine in 10 physicians (93%) reported care delays while waiting for health insurers to authorize necessary care. More than four in five physicians (82%) said patients abandon treatment due to authorization struggles with health insurers, and more than one-third (34%) of physicians reported that prior authorization led to a serious adverse event, such as hospitalization, disability, or even death, for a patient in their care.
• An investigation by the inspector general’s office of the Health and Human Services Department found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments, in some cases ignoring prior authorizations or other documentation necessary to support the payment.
• A Kaiser Family Foundation analysis found Medicare Advantage plans denied two million prior authorization requests in whole or in part, representing about 6% of the 35 million requests submitted in 2021. While about 11% of denials were appealed, the vast majority (82%) of appealed denials were fully or partially overturned, raising serious concerns about the appropriateness of many of the initial denials.

Patients, physicians, and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.