American Academy of Ophthalmology rallies against expanding prior authorization to Medicare Fee For Services

The Academy noted it is behind the CMS effort to streamline the prior authorization process, expressing its support for the regulatory changes in the rule and urging quick finalization of those policies this year. (Image Credit: Adobe Stock/New Africa)

The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed prior authorization rule intended to streamline the electronic exchange of healthcare information by reviewing the prior authorization process to respond to requests more efficiently.

While CMS is not expanding prior authorization to Medicare Fee For Service, it has simply asked in the proposed rule whether this should be considered, and organizations including the American Academy of Ophthalmology (AAO), have rallied against that idea.

According to CMS, the rule also would require payers to put in place standardized data exchange processes, to help them exchange data when a patient changes health insurers. If finalized, the policies would take effect in 2026. The rule, which the CMS estimates will save hospitals and doctor’s offices more than $15 billion over 10 years, replaces one proposed in the final days of the Trump administration that was controversial with health insurers.

CMS accepted comments on the proposed rule through March 13, and several organizations, including the Academy, chimed in with comments.

“The agency has clearly listened to cries from patients and healthcare providers urging more oversight of the unscrupulous tactics Medicare Advantage plans use to deny medically necessary care,” said Michael Repka, MD, medical director for health policy for the AAO.

Repka noted the proposed rule also reflects the concerns of Congress by including many elements of the Improving Seniors Timely Access to Care Act of 2021 (H.R. 3173/S. 3018), which had broad bipartisan support in the 117th Congress.

“We hope to see the bill reintroduced in the 118th Congress so that critical patient protections are codified into law,” Repka said.

Repka added that the time is now for policymakers to address the issue of prior authorization reform to ensure there is equal access to care for all Medicare beneficiaries.

“The state where a Medicare Advantage beneficiary lives should not determine whether they can receive the care they need in a timely fashion, which is, unfortunately, the situation in Georgia and Florida right now with Aetna and Humana Medicare Advantage plans requiring PA for cataract surgery,” he said.

In the letter, directed to CMS Administrator Chiquita Brooks-LaSure, the Academy noted it is behind the CMS effort to streamline the prior authorization process, expressing its support for the regulatory changes in the rule and urging quick finalization of those policies this year.

The Academy’s recommendations in its letter center around the following key concerns:

• Ensuring accountability through enforcement of decision deadlines and public reporting of denial metrics.
  
  
• Avoiding potential administrative burden for provider practices by removing the unnecessary Merit-Based Incentive Payment System (MIPS) Promoting Interoperability measure proposal.
  
  
• Adding protections for small and rural practices.
  
  
• Expanding application of the rule’s provision to address other key areas of concern such as health equity, step therapy, and Digital Imaging and Communications in Medicine (DICOM) standards.
  
  

The Academy did express some concern about how the rule could be used under Medicare fee-for-service.

"We ardently oppose prior authorization under Medicare fee-for-service and urge CMS to suspend any existing prior authorization policies on services not mandated by legislation," the AAO said in its letter to CMS. "We believe that prior authorization expansion in fee-for-service has the potential to harm Medicare patients' access to necessary care and should not move forward without a specific legislative mandate."

Moreover, the Academy noted in its letter it wants to make sure that beneficiaries enrolled in MA plans can get complete and timely access to the treatments necessary to manage their conditions.

“Along with many of our subspecialty partner organizations, the Academy has advocated against MA payers creating requirements that inappropriately delay and deny beneficiaries access to medically necessary care,’ the Academy added in its letter.

The Academy pointed out that while utilization management tools like PA may be appropriate in some circumstances, it isn’t right to require PA for services that are routine and medically necessary.

“Due to ongoing harm caused by poorly implemented and underregulated prior authorization policies, the Academy urges CMS to finalize the e-PA policies proposed in the rule and the Academy’s recommendations expeditiously,’ the letter concluded.

Other organizations also offered comments during the period.

In its comments, the American Medical Association (AMA) for the most part offered its support for the CMS plan to improve prior authorization.

The AMA supports Brooks-LaSure’s reform proposals and their “focus on the role of payer decision-making and electronic information exchange in the prior authorization process,” according to AMA President Jack Resneck, MD. “CMS has proposed two sets of rules on prior authorization, and as in comments on the initial rule, the AMA continues to applaud the administrator for acknowledging patient and physician concerns in both sets of proposed rules.”

The American Hospital Association (AHA) in its response to CMS, urged it to quickly finalize a proposed rule that would require Medicare Advantage, Medicaid and federally-facilitated Marketplace plans to streamline their prior authorization processes, but urged the agency to adequately enforce and monitor the requirements and test and vet any electronic standards before mandating their adoption.

“The proposed rule is a welcome step toward helping patients get timely access to care and clinicians focus their limited time on patient care rather than paperwork,” AHA wrote in its response to CMS. “However, to truly realize these benefits, we urge CMS to ensure a baseline level of enforcement and oversight. In addition, while hospitals and health systems appreciate CMS’ effort to improve the electronic exchange of care data to reduce provider burden and streamline prior authorization processes, we urge CMS to ensure that any electronic standards are adequately tested and vetted prior to mandated adoption.”