The ISMA has joined the AMA and medical societies across the country in urging the Centers for Medicare and Medicaid Services to adopt proposed rules regarding prior authorization (PA) reforms to Medicare Parts C and D.

Physician groups signing on to the Feb. 13 letter found several positive changes to PA in the proposal that the AMA and other groups have advocated for at the federal and state levels for years, including:

• Increased clinical validity of coverage criteria.
• Restrictions on retroactive denials after prior authorization approvals.
• A grace period for patients switching plans to promote continuity of care.
• Greater physician-patient autonomy in determining where care can be provided and by whom.
• Volume reduction by encouraging gold carding programs.
• Prior authorization information at the point of care.

According to recent AMA data, 93% of physicians report care delays or disruptions associated with PA. AMA data also showed that 34% of physicians report that PA has led to a serious adverse event for a patient in their care and that 91% of physicians see PA as having a negative effect on their patients’ clinical outcomes.

Additionally, a 2022 Office of the Inspector General (OIG) report found that 13% of PA requests denied by Medicare Advantage (MA) plans met Medicare coverage rules, and 18% of denied payment requests met Medicare and MA billing rules.

“We applaud CMS’ proposed policy responses to the findings of the OIG’s report and to ongoing stakeholder concerns and urge CMS to finalize these policies to help protect beneficiaries’ access to medically necessary care,” the letter states.

Read the letter >>