Hospitals and providers say federal regulators should seek authority from Congress to require Medicare Advantage plans to pause prior authorization requirements during future public health emergencies.
The Centers for Medicare and Medicaid Services allowed MA plans to relax or waive prior authorization requirements for patient transfers to post-acute care facilities during 2020 due to the COVID-19 public health emergency. But as the PHE continued, many plans reinstated requirements for plan year 2021. CMS' proposed rule says hospitals have told the agency that more patient transfer flexibilities from MA plans could ease bed scarcity.
CMS requested information in a recent proposed rule about the impact of MA plans' prior authorization requirements for patient transfers on hospitals' care and time management capabilities during a public health emergency.
Post-acute care facilities have been key to pandemic response, providing specialized care to patients who are sick with—and recovering from—COVID-19, the American Hospital Association emphasized in a comment letter to CMS submitted Monday.
But insurers' prior authorization policies often lead to delayed discharge, meaning providers must use limited acute-care resources on patients that could have benefited from care elsewhere, AHA said. This has caused extra strain on hospitals during the PHE, when many hospitals around the country have operated at full capacity and even delayed non-essential care during COVID-19 surges.
"We recognize that prior authorization is a tool that, when used appropriately, can help align patients' care with their health plan benefit structure and facilitate compliance with clinical best practices. However, its misuse and application during a PHE has negatively affected patient care and the delivery system's response to a global health crisis," AHA said.
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AHA said plans' inconsistent use of prior authorization waivers have made operations particularly difficult for post-acute care providers like inpatient rehabilitation facilities and long-term care hospitals, which are sometimes excluded from prior authorization waivers.
The American Medical Rehabilitation Providers Association, which represents inpatient rehabilitation facilities, echoed this in its own comments to CMS.
AMRPA surveyed 475 inpatient rehab facilities across the United States last August and found that about 52% of initial requests for patient transfers into inpatient rehab were denied. Providers and patients had to wait an average of 2.59 days for a denial from an MA plan, and 2.49 days for an approval. The survey encompassed 30,926 unnecessary days that patients spent in acute-care hospitals when providers believed post-acute care would have been appropriate.
The data shows MA plans are inappropriately limiting inpatient rehab facility access through prior authorization, AMRPA contends. According to the organization, MA beneficiaries represented only 20% of Medicare inpatient rehab admissions in 2019, despite representing about 36% of all Medicare enrollees. When prior authorization waivers became widespread at the start of the pandemic, MA and traditional Medicare beneficiaries' admissions to inpatient rehabs became more proportional, AMRPA said.