The volume of prior authorization determinations varied across Medicare Advantage insurers, ranging from 0.3 requests per Kaiser Permanente enrollee to 2.9 requests per Anthem enrollee.More than 35 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees.Unfortunately, we were not able to analyze prior authorization rates by type of service or type of plan because CMS does not collect or report this information. ![]() We used these data to examine the use of prior authorization in Medicare Advantage during the 2021 calendar year (the most recent year for which data are available). Insurers are additionally required to indicate the number of initial decisions that were appealed and the outcome of that process. Prior authorization may play a role in helping Medicare Advantage plans reduce costs and maintain profits.Īs part of its oversight of Medicare Advantage plans, CMS requires Medicare Advantage insurers to submit data for each Medicare Advantage contract (which usually includes multiple plans) that includes the number of prior authorization determinations made during a year, and whether the request was approved. Most commonly, higher cost services, such as chemotherapy or skilled nursing facility stays, require prior authorization. However, virtually all Medicare Advantage enrollees (99%) were enrolled in a plan that required prior authorization for some services in 2022. That is still the case for beneficiaries enrolled in traditional Medicare, who are only required to obtain prior authorization for a limited set of services. Historically, Medicare beneficiaries were rarely required to receive prior authorization. In the fall of 2022, the House of Representatives passed bi-partisan legislation that would require Medicare Advantage insurers to establish an electronic process for real-time prior authorization determinations, but it did not pass the Senate and become law. The second proposed rule clarifies the criteria that may be used by Medicare Advantage plans in establishing prior authorization policies and the duration for which a prior authorization is valid. The provisions in the first proposed rule are intended to improve the use of electronic prior authorization processes, as well as the timeliness and transparency of decisions, and apply to Medicare Advantage and certain other insurers. In response to these concerns, the Centers for Medicare and Medicaid Services (CMS) published two proposed rules in December 2022 that include provisions related to prior authorization requirements (among other policy changes). ![]() ![]() While prior authorization has long been used as a tool to contain spending and prevent people from receiving unnecessary or low-value services, there are some concerns that current prior authorization requirements and processes may create barriers and delays to receiving necessary care, as well as exacerbate complexity for patients and their providers. Prior authorization is intended to ensure that health care services are medically necessary by requiring providers to obtain approval before a service or other benefit will be covered by a patient’s insurance.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |