AMGA Calls for Stricter Oversight and Reform of Prior Authorization in Medicare Advantage
AMGA today called on the Centers for Medicare & Medicaid Services (CMS) to enhance oversight of prior authorization practices within the Medicare Advantage (MA) program. In a letter to the CMS, AMGA highlighted the detrimental impact of current prior authorization practices on patient care and urged for comprehensive data collection to help inform policy changes to address these issues.
Risk Adjustment Changes Add to Provider Financial Struggles
Alexandria, VA – AMGA today called on the Centers for Medicare & Medicaid Services (CMS) to enhance oversight of prior authorization practices within the Medicare Advantage (MA) program. In a letter to the CMS, AMGA highlighted the detrimental impact of current prior authorization practices on patient care and urged for comprehensive data collection to help inform policy changes to address these issues.
AMGA's members have raised concerns that the existing prior authorization processes often lead to significant delays and denials of medically necessary care. AMGA is recommending CMS collect detailed and specific data on how plans use prior authorization, what role subcontractors have in the process, and how frequently initial denials are overturned on appeal. AMGA believes this data will illustrate that prior authorization is overused and is not necessary in most instances.
“Prior authorization has become a costly obstacle course that providers and patients must navigate,” said AMGA President and CEO Jerry Penso, MD, MBA. “Denials that eventually approved after delays and appeals are not adding value to Medicare Advantage for patients, providers, or CMS.”
AMGA also reiterated its concerns with the transition to version 28 of the CMS Hierarchical Condition Category (CMS-HCC) model. AMGA urged CMS to reconsider the continued shift to this model, as it has resulted in significant changes to both plan benefit designs and reimbursements. AMGA members are facing the possibility of reducing staff, eliminating programs, and reevaluating their strategic plans, including the continued transition to value-based care, to account for reductions in MA payments.
“Providers are reimbursed less for providing care to patients with chronic, complex conditions, just because of changes to the risk adjustment model,” Penso added. “Providers already are facing significant financial challenges, and this situation cannot continue to go unaddressed without an impact to services, staffing, and operations of our member groups.”
The letter is available on the AMGA website.
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About AMGA
AMGA is a trade association leading the transformation of healthcare in America. Representing multispecialty medical groups and integrated systems of care, we advocate, educate, innovate, and empower our members to deliver the next level of high performance health. AMGA is the national voice promoting awareness of our members’ recognized excellence in the delivery of coordinated, high-quality, high-value care. More than 175,000 physicians practice in our member organizations, delivering care to one in three Americans.
AMGA represents medical groups and integrated systems of care. Its diverse membership includes multispecialty medical groups, integrated delivery systems, accountable care organizations, and other entities committed to improving healthcare outcomes. AMGA advocates for the formation of innovative, clinically integrated systems of care that advance population health, enhance patient experience, and reduce healthcare costs. For more information, please visit www.amga.org.