The Centers for Medicare and Medicaid Services removed prior authorization requirements for a small set of orthopedic procedures as regulators continue to adjust the controversial approval process.
CMS issued a final rule Tuesday that indefinitely suspended prior authorization for urgently needed procedures involving spine and knee braces. The agency announced in January that it will more frequently update the mandatory list of durable medical equipment, prosthetic and orthotic procedures requiring insurers’ approval before providers are paid.
CMS looks to add procedures to the prior authorization list that have irregular billing patterns, are high cost and low value, or have been identified in a government report. Regulators will remove prior authorization requirements for treatment that are low cost, low risk and high value, the agency said.
The removal of prior authorization for infrequently overused and high-value clinical services is an important step forward, said Dr. Mark Fendrick, a professor of internal medicine and health management and policy at the University of Michigan.
“This is a service that most would say doesn’t need to have a barrier. Let’s not put up barriers for clinical services that help people and are infrequently overused,” he said. “There’s too much attention on how prior authorization is actually implemented as opposed to the services for which prior authorization is placed.”
Prior authorization has long been a sticking point between providers and insurers. The intent is to weed out procedures prone to fraud and abuse, unnecessarily expensive or ineffective. But it has led to delays in patient care and increased administrative costs, providers say.
While it’s unclear whether the update indicates a larger policy shift to reevaluate CMS' approach to expand prior authorization within Medicare Part B, the adjustment is a step in the right direction, said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association.
“We’re pleased to see that CMS is evaluating prior authorization in the context of providing timely care to Medicare beneficiaries. As an organization, MGMA has strongly advocated for limiting the use of prior authorization in Medicare Part B, where it is generally limited,” Gilberg said in an email.
A House committee advanced a bill last month that would streamline prior authorization requirements for Medicare Advantage carriers. Those insurers would have to establish electronic prior authorization programs that provide real-time decisions on certain items and services.
About 13% of prior authorization denials by Medicare Advantage plans were for benefits that would otherwise have been covered under Medicare, according to an April report from HHS’ Office of Inspector General.
CMS finalized a regulation last year to digitize the prior authorization process for Medicaid and private health plans offered through the exchanges. While the rule was withdrawn, the agency in January asked for input on electronic prior authorization standards.
“Moving forward, we should pay attention to not only streamlining the process of prior authorization, but hopefully create additional rules that remove prior authorization for services of high clinical value and add more prior authorization for services that at best provide no clinical benefit and in some situations may cause harm,” Fendrick said.
