CMS Urged to Reform Prior Authorization to Avoid Harm to Patients with Cancer

March 17, 2020

The Association for Clinical Oncology (ASCO) recently submitted comments in response to Part II of the Centers for Medicare & Medicaid Services’ (CMS) calendar year 2021 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies. The advance notice proposes updates and changes to the methodologies used to pay Medicare Advantage plans, Programs of All-Inclusive Care for the Elderly organizations, and Part D sponsors. ASCO’s comments recommend ways to address the challenges patients and physicians face when navigating prior authorization requirements and suggest areas for quality measurement in prior authorization programs.

ASCO believes that payers can mitigate administrative burden by focusing prior authorization requirements on specific areas of concern and by providing an efficient, transparent process within a reasonable timeline. Such recommendations, to name a few, include standardizing prior authorization request forms and processes; integrating prior authorization processes into electronic health records; and using a public process to determine prior authorization policies for cancer treatment.

With ASCO’s recommendations as a starting point, the Association also suggests a number of potential quality measures for prior authorization programs. The suggested measures are organized into three areas:

  • Program design—re-evaluating the timeline throughout the entire prior authorization process
  • Administrative burden—streamlining processes in prior authorization by standardizing forms and making records public
  • Avoidance of patient harm—mitigating health care delays and treatment interruptions for patients with cancer

“From the time of notification of a required prior authorization through to an ultimate decision being rendered, precious hours and days—sometimes weeks—are slipping away from a patient whose disease may be progressing, whose symptoms may be spiraling out of control, and who may be losing hope for a cure,” said ASCO Chair of the Board Monica M. Bertagnolli, MD, FACS, FASCO. “We therefore recommend that CMS pay close attention to the issue of timeliness when considering potential quality measures in the area of prior authorization.”

ASCO will continue share the cancer community’s perspective and work with CMS at every opportunity to improve access to care for people with cancer.

Read the full letter.

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