Regulatory Relief Campaign
As part of its ongoing regulatory relief advocacy campaign, the Academy believes that current prior-authorization requirements in the Medicare Advantage (MA) program put unnecessary burdens on physicians. MA plans may not impose barriers to medically necessary care and must provide the same coverage as Medicare Fee-for-Service. The Academy has shared legal arguments with the Centers for Medicare & Medicaid Services about how MA plans may use the prior authorization tool and has pressed the agency to provide stronger guidance to MA plans on their use of prior authorization requirements.
In 2019, the Academy-led Regulatory Relief Coalition secured the introduction of legislation to address prior authorization abuses in the MA program. The Improving Seniors’ Timely Access to Care Act seeks to address the lack of transparency, delays to patient care, and physician burdens brought on by increased prior authorization usage under Medicare Advantage plans. H.R. 3107 was introduced by Reps. Suzan DelBene, D-Wash., Mike Kelly, R-Penn., Ami Bera, MD, D-Calif., and Roger Marshall, MD, R-Kan., in June 2019, and the bill has more than 260 cosponsors.
Prior Authorization/Step Therapy During the COVID-19 Pandemic
During the COVID-19 pandemic, the Academy has heard from many ophthalmology practices asking for relief from MA plans’ prior authorization and step therapy requirements for age-related macular degeneration intravitreal injections and other treatments. The Academy reached out to the CMS to let them know about these concerns from ophthalmologists. We urged the agency to mandate that MA plans to suspend prior authorization and step therapy requirements during the COVID-19 pandemic. In April 2020, CMS released updated guidance for MA plans and announced that these plans may choose to waive or relax plan prior authorization requirements at any time in order to facilitate access to services with less burden on beneficiaries, plans, and providers.
Earlier this year, the Academy’s Regulatory Relief Coalition also released an open letter to health plans urging them to waive prior authorization and similar utilization review requirements during the COVID-19 pandemic. In addition, our Coalition called on state governors and insurance commissioners to act to prohibit these obstacles to care for the duration of the pandemic.
Prior Authorization for Part B Drugs in Medicare Advantage
In July 2020, the Academy joined nearly 200 patient and provider groups in urging our nation’s top health care leaders to restore “unfettered” access to Part B-covered drugs under the Medicare Advantage program. CMS must work to remove obstacles for patients that are delaying treatment.
Prior Authorization in the Hospital Outpatient Setting
Implementation of CMS’ new prior authorization process for some hospital outpatient surgeries July 1, 2020, has resulted in a slowed and disruptive approval process for certain procedures, including blepharoplasty.
The Academy learned that a number of Medicare Administrative Contractors (MACs) have not properly implemented the new policy, resulting in delays in surgery in many states. Specifically, MAC’s problems with processing such prior authorization requests are unnecessarily burdening ophthalmologists and patients. Although CMS did not accommodate our request with Otolaryngology and Neurology for delay of implementation of the policy, they are reiterating a commitment for MACs to provide a response to prior authorization requests within 10 days.
The process that CMS finalized for hospitals to submit prior authorization requests applied to five categories of services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. The process allows practices to get confirmation of a patient’s coverage before providing an outpatient service and submitting for processing.
The Academy led a meeting with CMS and representatives of otolaryngology and neurology. The Academy is continuing to pursue multiple regulatory and congressional avenues to address delays and denial issues caused by this policy.