February 28, 2019
The Honorable Seema Verma Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 445–G 200
Independence Avenue, SW
Washington, DC 20201
Dear Administrator Verma:
The undersigned organizations are writing to urge the Centers for Medicare & Medicaid Services (CMS) to provide guidance to Medicare Advantage (MA) plans on prior authorization (PA) processes through its 2020 Call Letter. CMS’ guidance should direct plans to target PA requirements where they are needed most. Specifically, CMS should require MA plans to selectively apply PA requirements and provide examples of criteria to be used for such programs, including, for example, ordering/prescribing patterns that align with evidencebased guidelines and historically high PA approval rates.
At a time when CMS has prioritized regulatory burden reduction in the patient-provider relationship through its Patients Over Paperwork initiative, we believe such guidance will help promote safe, timely, and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.
A Consensus Statement on Improving the Prior Authorization Process, issued by the AMA, the American Hospital Association, America’s Health Insurance Plans, the American Pharmacists Association, Blue Cross Blue Shield Association, and the Medical Group Management Association in January 2018, identified opportunities to improve the prior authorization process, with the goals of promoting safe, timely, and affordable access to evidence-based care for patients; enhancing efficiency; and reducing administrative burdens.1 It notes that the PA process can be burdensome for all involved—health care providers, health plans, and patients—and that plans should target PA requirements where they are needed most. Providers and health plans agree that making policy changes that eliminate PA on services for which there is low variation in care, promote greater transparency regarding which services are subject to PA, and protect patients to ensure PA does not impact continuity of ongoing care are essential. We urge CMS to require MA plans to follow the important concepts outlined in the Consensus Statement to improve MA patients’ access to timely, medically necessary care.
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