The Centers for Medicare and Medicaid is evaluating whether it needs to take further steps cracking down on health insurance companies' prior authorization requirements.
Patient and provider annoyance with prior authorization has boiled over in recent years, which CMS Administrator Chiquita Brooks-LaSure acknowledged at the American Hospital Association's annual conference in Washington, D.C., on Monday.
"The volume of frustration that I hear about prior authorization has just exploded, and I think it is really at a point where it is affecting care and our workforce in a way that is extremely problematic," she told the gathering.
Related: How CMS’ prior authorization rule will affect insurers
The agency in January issued a final rule requiring Medicare Advantage, Medicaid, Children’s Health Insurance Program and exchange plans to respond to standard prior authorization requests within seven days and to "urgent" requests within three days. Among other provisions, the rule also requires prior authorization decisions to be automatically embedded in a patient's electronic health record.
Brooks-LaSure did not provide specifics on what might come next from CMS, but she made it clear the agency doesn't see itself as done.
"I think that we have taken some really important steps in our rules. We've done the rules that are broad across the industry and also specific to Medicare Advantage. But we want to continue to look and hear about how things are operating. I've been hearing a lot about prescription drugs," LaSure said. "That's an area that we have been asked to look at, and we are open to do that."
Before new rule proposals, though, she said insurance companies have the opportunity to make changes.
"I also think there's room for the private sector, and I've told the health plans this — it doesn't have to all be regulated from us. There may be things that they can do," Brooks-LaSure said, suggesting that plans could at least look at reducing complexity.
"We, CMS, can try to help navigate that, but some of that might also be things that the private sector could do without us having to tell everyone what to do," Brooks-LaSure said.
Insurers such as UnitedHealth Group, Cigna and Blue Cross Blue Shield of Michigan have dialed back some prior authorization requirements on their own amid public pressure.
Ashley Thompson, AHA's senior vice president of public policy analysis and development, asked Brooks-LaSure about CMS' enforcement intentions regarding the prior authorization rule and its steps to tighten restrictions on Medicare Advantage plans.
Brooks-LaSure suggested it would be a collaborative effort with providers and said CMS has its eye on Medicare Advantage.
"We have people all over, in our regional offices, all over the country who do so much casework when they hear of problems, and when we see them across the board, we can speak to the companies or individuals," Brooks-LaSure said.
She said the agency was "agnostic" about whether people choose Medicare Advantage plans or traditional Medicare, but "we want whichever one they choose ... to be strong, meaningful options for them."
She appeared to be referring to the rules the agency has issued reining in marketing practices by Medicare Advantage plans.
CMS deciding to issue more rules is a possibility, she said.
"We continue to look at prior authorization, and of course we are strengthening our oversight," she said. "You've probably also seen that we continue to ask for more data from Medicare Advantage plans, because we want to make sure that we know that the dollars are being given to patient care, and that's another way that we're trying to make sure that the dollars are being spent well."
