Physician organizations pressed for more clarity in a federal rule about the training and experience of reviewers who handle disputes about prior authorization for some Medicare plans while also welcoming proposals intended to streamline this process in general.

Centers for Medicare & Medicaid Services (CMS) hopes to use an annual policy update for insurer-run Medicare Advantage and Part D plans to address doctors’ longstanding concerns about prior authorization.

The draft 2024 update requires insurers to ensure that enrollees in Medicare Advantage plans have access to the same treatments and medications they would under traditional fee-for-service Medicare.

CMS also said that it intends to more precisely define what kinds of clinicians handle cases of partial or full coverage denials while still allowing insurers flexibility in selecting appropriate reviewers.

This has long been an area of concern for clinicians. The American Medical Association and American Academy of Family Physicians were among the groups who said that physicians often have to deal with insurers’ clinicians who lack the needed expertise on patient care. This leads to delays and denials of treatment, they said.

Defining Expertise

In the proposed rule, CMS updates current regulations requiring reviewers have “sufficient medical and other expertise” to now require “requisite experience.” But CMS also said that insurers don’t need to hire physician reviewers with the same specialty or subspecialty as the treating physician.

Instead, Advantage plans will continue to have discretion to determine case-by-case what constitutes appropriate expertise, CMS said. For example, how long will it take for buspirone to work a health plan that intends to deny a request for a home nebulizer could have that case reviewed by a respiratory therapist.

CMS drew praise from trade group America’s Health Insurance Plans for stopping short of requiring a specialist-to-specialist interaction. The insurers’ group said that requiring a match of specialties between reviewers and ordering physicians would be “cost-prohibitive” and “highly problematic.”

‘Prior Auth Purgatory’

There’s widespread agreement about the need to improve how insurers review physician requests for coverage.

In December, CMS also issued a separate sweeping proposed rule about prior authorization. This more ambitious proposal would affect not only Advantage plans, but also state Medicaid fee-for-service and Children’s Health Insurance Program fee-for-service programs, Medicaid managed care plans, and the private health plans sold through health exchanges.

But insurer-run Medicare plans pose additional challenges not experienced with traditional Medicare or commercial plans, Vanderbilt University Medical Center told CMS in a comment.

These include more frequent requests and more frequent denials as well as taking longer to make decisions on prior authorizations. In addition, health plans often are inflexible about setting meeting times, sometimes refuse peer-to-peer meetings and insist on conversations with attending physicians, which delays discussions prior to discharge of patients.

There’s clearly a need for better processes, said A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan.

“We want it to be more efficient and faster and less onerous on the clinicians and keep patients out of what I call the prior [authorization] purgatory,” Fendrick told Medscape in an interview.

Arguments for Prior Authorization

But the compelling arguments for requiring prior authorization for some treatment are often obscured in the discussions about insurers’ approach to implementing it, Fendrick said.

“The fundamental reason to have a prior authorization is to ensure that patients get the care they need to improve their health and to deter the use of that care that, at best, doesn’t make them healthier, but in some cases actually causes harm,” Fendrick said.

Insurers need to better explain the reasons why they deny coverage for certain services and treatments, said Fendrick, who last year published the Health Affairs article “Reframe The Role Of Prior Authorization To Reduce Low-Value Care.”

Fendrick notes in the article that a refusal to cover a prostate cancer screening for a man older than 70 would count as a declined prior authorization, even though the US Preventive Services Task Force (USPSTF) recommends against its use for that population.

“Health plans can help themselves here by demystifying criteria used for prior authorization as “the lack of transparency around criteria used for such determinations creates unnecessary friction and provider burdens” Fendrick wrote.

Fendrick has reported having had financial relationships and consulting arrangements with AbbVie, Amgen, Arnold Ventures, Bayer, CareFirst, BlueCross BlueShield, Centivo, Community Oncology Association, EmblemHealth, Employee Benefits Research Institute, Exact Sciences, GRAIL, Health at Scale Technologies*, HealthCorum, Hygieia, Johnson & Johnson, MedZed, Merck, Mercer, National Pharmaceutical Council, Phathom Pharmaceuticals, Proton Intelligence Inc., RA Capital, Sempre Health, Silver Fern Health, Teladoc Health, US Department of Defense, Virginia Center for Health Innovation, Washington Health Benefit Exchange, Wellth, Yale-New Haven Health System, PCORI, PhRMA, RWJ Foundation, State of Michigan/CMS.

Kerry Dooley Young is a freelance journalist based in Miami. Follow her on Twitter @kdooleyyoung.

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