A new report found that 13% of prior authorization denials in the Medicare Advantage (MA) program were for service requests that met Medicare fee-for-service coverage rules, likely delaying or preventing patient care. The report, conducted by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), on the impact of prior authorization within MA found that imaging services, stays in post-acute facilities, and injections were three prominent service types among the denials that met Medicare coverage rules.
The Association for Clinical Oncology (ASCO) is extremely concerned about the findings in this report, especially the details related to patients with cancer. Eight cases featured in the report were related to cancer care, six of which were denied based on incorrect determinations, clerical errors, incorrect data review, etc. Specific examples include:
- An 81-year-old patient with cancer of the lining of the uterus was denied a CT scan of the chest, abdomen, and pelvis. The decision was reversed after provider appeal.
- An 89-year-old patient with Parkinson’s disease, dementia, and prostate cancer was denied discharge from the emergency department to an Independent Rehabilitation Facility. The decision was reversed upon appeal.
- A 53-year-old patient with multiple myeloma was denied a blood draw. The Medicare Advantage Organization (MAO) said the prior approval covered chemotherapy, not lab work. The decision was not reversed, despite an existing valid prior authorization for lab work.
- In a couple instances MAOs were found to have misapplied Medicare coverage rules to deny injections for pain management—a critical component of cancer care.
While many of the denials were reversed on appeal (some after identification by the OIG), the appeal process can be arduous and time consuming, on top of the delays the prior authorization process can cause in the first place. Any delay in appropriate cancer care can be devastating to patients and result in disease progression.
The OIG report makes several recommendations to the Centers for Medicare & Medicaid Services to improve prior authorization in MA, including:
- Issuing new, clarifying guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.
- Updating audit protocols to address the issues identified in the OIG report.
- Directing MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review and system errors.
ASCO has long advocated for streamlined prior authorization processes to stop delays in care and reduce administrative burdens. For example the 2017 policy statement by our affiliate organization on the impact of utilization management practices for cancer drug therapies made specific recommendations to improve prior authorization.
Federal Prior Authorization Reform Gains Momentum
ASCO supports the recommendations of the OIG report and believes congressional action could compel swift and uniform change amongst MA plans. ASCO has been a strong supporter of H.R. 3173/S. 3018, the Improving Seniors’ Timely Access to Care Act, which would create an electronic prior authorization process in MA, hold MA plans accountable for the timeliness of determinations, and require plans to report on the extent of their prior authorization use. Garnering support for the bill has been a key policy “ask” during the annual ASCO Advocacy Summit and Week of Action for several years. As a result, the bipartisan bill now has 284 House cosponsors and 24 Senate cosponsors.
The OIG report highlights delays or denials of care that ASCO and patient and provider communities have been well aware of. The time is now for Congress to take action and pass the Improving Seniors’ Timely Access to Care Act. Lawmakers need to hear from experts in the field on how critical passage of this bill is to bring it across the finish line.
Contact your members of Congress in seconds to ask them to pass the legislation using the ACT Network, and mark your calendar for ASCO’s Prior Authorization Week of Action May 16-20, 2022.
Read the full OIG report.
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