Prior Authorization Reform

AAPM&R has been working to reform prior authorization for several years due to the burden it puts on physiatrists and the barriers to rehabilitation care it creates.

Your Academy is prioritizing:

• The lack of transparency with plans using proprietary guidelines to deny care
• The flaws of the “peer-to-peer” system
• Decreasing lengthy response times from plans conducting authorizations
• Advocating for Congress and CMS to implement common-sense reforms to the prior authorization process

Federal and State Advocacy Actions in 2024:

• Your Academy endorsed the Improving Seniors’ Timely Access to Care Act (H.R. 8702/S. 4532). This bipartisan legislation would help protect patients from unnecessary delays in care by streamlining and standardizing the prior authorization process under the Medicare Advantage program. Please see the Regulatory Relief Coalition’s website for more information on the progress of this bill.
  
  

• The majority staff of the Senate Homeland Security & Government Affairs Committee recently released a report detailing how several Medicare Advantage (MA) insurers deny claims for post-acute care at significantly higher rates than they do for other services. This report, Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care, builds off an investigation that began in May 2023. This report highlights the urgent need for reform of the prior authorization process, particularly under the MA program, and the need for Congress to immediately pass the Improving Seniors’ Timely Access to Care Act.

• Learn about the Senate investigation that reveals Medicare Advantage insurers deny post-acute care at much higher rates than other services.

• CMS published its Interoperability and Prior Authorization Final Rule on January 17. Once implemented, this rule will require covered payers to establish electronic prior authorization systems, transmit prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, provide a specific reason for denying prior authorization appeals, and publicly report metrics for prior authorization. The release of this final rule came after years of advocacy efforts focused on prior authorization reform by the Academy and the Regulatory Relief Coalition, and is a significant win for PM&R physicians and their patients. Learn more about AAPM&R’s advocacy on this issue.
• On April 30, AAPM&R held our annual Day on the Hill in Washington, D.C. Eight of our Health Policy and Legislation (HP&L) Committee members met with Congressional offices and asked for Congressional support for the Improving Seniors’ Timely Access to Care Act and other PM&R legislative priorities.
• On June 25, members of AAPM&R’s Future Leaders Program visited Washington, D.C., to advocate on behalf of the specialty. All 10 members of the program, along with the chairs of AAPM&R’s State Advocacy Committee and Membership Committee, met with Congressional offices to ask for Congressional support for the Improving Seniors’ Timely Access to Care Act and other PM&R legislative priorities.
• Your Academy submitted comments to the Centers for Medicare & Medicaid Services regarding the 2025 Outpatient Prospective Payment System proposed rule.  The Academy’s comments focused on the need for prior authorization (PA) reform and thanking CMS for its work to streamline this burdensome process for certain hospital outpatient department services.
• Your Academy endorsed S. 4349, the Electronic Prior Authorization for Prescription Drugs Act. This bipartisan legislation, introduced by Senators Roger Marshall, MD (R-KS), Ben Ray Lujan (D-NM), Roger Wicker (R-MS), and Joe Manchin (I-WV), would establish electronic PA procedures for prescription drugs in the private market.
• Your Academy responded to a Request for Information (RFI) from the Centers for Medicare and Medicaid Services (CMS) related to data policies under the Medicare Advantage (MA) program. AAPM&R’s comments largely focused on the need for CMS to collect more data related to prior authorization barriers currently impacting PM&R physicians and patients attempting to access rehabilitation care under the MA program. AAPM&R also joined coalition responses to this RFI from the Regulatory Relief Coalition and the Coalition to Preserve Rehabilitation.
• Your Academy joined the Regulatory Relief Coalition (RRC) on a coalition letter urging CMS to halt implementation of a proposed demonstration project that would require Ambulatory Surgical Centers to obtain prior authorization before providing certain surgical procedures to Medicare beneficiaries.
• Your Academy endorsed H.R. 5213, the Reducing Medically Unnecessary Delays in Care Act, along with the Regulatory Relief Coalition. This legislation, introduced in the U.S. House of Representatives, would require all prior authorization decisions and adverse determinations under Medicare, MA, and Part D to be made by a licensed physician who is board-certified in the specialty relevant to the request.

Federal and State Advocacy Actions in 2023:

• Your Academy hosted a webinar, “Challenging Medicare Advantage Denials of PM&R Physician Services,” to inform Academy members of new tools available to physiatrists combatting prior authorization denials by Medicare Advantage plans. This resource is available for download in the Academy’s Education Center.
• Your Academy joined the Regulatory Relief Coalition in responding to a request for information from the U.S. House of Representatives’ Budget Committee Health Care Taskforce soliciting input on actions Congress could take to improve health care outcomes while reducing spending. These comments focused on advocating for common-sense reforms to the prior authorization that we believe Congress should implement.
• Your Academy endorsed H.R. 4968, the Getting Over Lengthy Delays in Care As Required by Doctors (GOLD CARD) Act, legislation that would allow Medicare Advantage plans to waive or reduce prior authorization requirements for clinicians who demonstrate a track record of compliance with a plan’s procedures. Your Academy joined a coalition letter led by the Regulatory Relief Coalition (RRC) thanking the sponsors of this legislation for their work to reform the prior authorization process for physicians.
• Your Academy joined a coalition letter from the Regulatory Relief Coalition (RRC) sent to the U.S. House of Representatives Committee on Ways and Means to thank them for their work on healthcare legislation that included provisions to reform and improve the prior authorization process.
• A bipartisan majority of Congress, 61 Senators and 233 Representatives, joined together to send a letter to the Centers for Medicare and Medicaid Services (CMS) urging swift finalization of regulations that streamline and reform the prior authorization process. Academy members sent over 350 messages to their congressional representatives urging support for this letter and for common-sense reforms to the prior authorization process.

Comment and Sign-On Letters:

• AAPM&R Joins RRC Letter Requesting Congress to Pass the Improving Seniors' Timely Access to Care Act (10.14.24)
• AAPM&R Comments to CMS on Service Level Data Collection for Medicare Advantage Plans (10.8.24)
• AAPM&R Comments to CMS on CY 2025 Outpatient Prospective Payment System (OPPS) Proposed Rule (9.9.24)
• AAPM&R Comments to CMS on MA Data RFI (5.29.24)
• AAPM&R Joins RRC Letter Regarding MA Data Proposed Rule (5.29.24)
• AAPM&R Joins CPR Letter Regarding MA Data Proposed Rule (5.29.24)
• AAPM&R Joins RRC Letter Regarding Prior Authorization Demonstration for Certain Ambulatory Surgical Center Services (4.17.24)
• RRC Comments on 2025 Medical Advantage Proposed Rule (1.5.24)
• CPR Comments on 2025 Medicare Advantage Proposed Rule (1.5.24)
• RRC Letter of Support for Reducing Medically Unnecessary Delays in Care Act (11.27.23)
• RRC Response to Budget Committee RFI for Improved Health Care Outcomes While Reducing Spending (10.18.23)
• Multispecialty Medical Society Letter to Washington, DC Council in Support of Prior Authorization Reform Act  (10.3.23) 
• Fighting to Reduce Physiatrist Burden by Reforming the Prior Authorization Process (4.21.23)
• Regulatory Relief Coalition Thank You Letter for Senate Hearing, "Examining Health Care Denials and Delays in Medicare Advantage" (5.26.23) 
• AAPM&R Comments on CMS Proposed Rule on Improving Prior Authorization Processes for Medicare Advantage (MA) Organizations (3.13.23) 
• AAPM&R Comments to CMS on Medicare Advantage (MA) Part D Proposed Rule (2.10.23)