AMGA Calls for Prior Authorization Improvements

Alexandria, VA – AMGA today recommended that the Centers for Medicare & Medicaid Services (CMS) reduce the use of prior authorization, which serves as an administrative burden and an impediment to timely healthcare delivery. In comments on a CMS’ proposed rule designed to improve the prior authorization process, Advancing Interoperability and Improving Prior Authorization Processes, AMGA supported the overall goals of the proposal, but emphasized the need to exempt more providers from the need to use prior authorization. 

“If prior authorization is intended to prevent inappropriate utilization, it’s simply not working that way,” said Jerry Penso, MD, MBA, AMGA president and CEO. “Plans are approving the requests, but only after a lengthy delay. This is more than just an inconvenience for patients. It can have serious ramifications.”

AMGA specifically recommended that CMS require plans to respond to prior authorization requests in a much shorter timeframe than proposed: 48 hours for standard requests and 24 hours for urgent ones. In addition, AMGA recommended requests be deemed approved if plans missed the deadlines.  

AMGA also endorsed a proposal to require plans to establish and maintain a provider access application programming interface (API), which would facilitate data sharing between the plans and providers.  However, AMGA recommended CMS expand its proposal and require plans to share data with all providers that have a relationship with a plan’s patient, even if the provider does not have a contractual relationship with the plan.  

“Access to patient data is critical. It’s the lynchpin of any successful population health initiative or value-based care model,” Penso said. “Having a complete picture of a patient’s medical history—their tests, screenings, vaccines, and medicines—will eliminate redundancy and improve care. Sharing data is an effective way to ensure appropriate care is provided, much more so than a blunt instrument like prior authorization.”  

The full letter is available on AMGA’s 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.