Valued Voice

WHA Urges CMS to Improve Prior Authorization and Other Insurer Issues in Proposed Medicare Advantage Rule

The Wisconsin Hospital Association is urging the Centers for Medicare & Medicaid Services (CMS) to minimize the negative care impacts prior authorization has on patients and providers while also improving various other insurer-related issues that have been cropping up in Medicare Advantage (MA).

In a March 4 comment letter, WHA detailed the myriad challenges for patient care that have been increasing in MA over the last few years due to growing insurer red tape. Perhaps most notable was the impact prior-authorization had on the post-acute care crisis that developed over the course of the pandemic. With general acute-care beds filled to capacity and nursing homes experiencing a severe worker shortage, prior authorization created another hurdle that delayed discharges and prevented hospitals from freeing up more beds for patients who needed them.

WHA's comment letter also called out the added administrative burden MA plans' prior authorization protocols required, which draw nurses and physicians away from patient care to navigate the complex prior authorization labyrinth. Furthermore, some MA plans require prior authorization even for services that have no evidence of abuse, as shown by a 2018 Office of Inspector General report that found MA plans overturned 75% of their own denials. WHA called on CMS to require MA plans to waive these burdensome processes during a pandemic.

In addition to prior authorization, WHA urged CMS to improve accountability for health insurers participating in MA. Recent insurer policies such as "white bagging" and requiring "designated diagnostic providers" have highlighted insurers' willingness to pull health care providers out of network, thereby disrupting patient care, during the middle of a benefit year for patients and without transparency for their enrollees. WHA encouraged CMS to beef up applicable network adequacy standards to improve oversight and urged greater transparency in the calculation of medical loss ratio reporting to guard against insurers sheltering profits.

Contact WHA Senior Vice President of Public Policy Joanne Alig with questions.