Prior Authorization Reform in Medicare Advantage (MA)

Priorities:

1. Decreasing lengthy response times
2. Addressing the flaws of the “peer-to-peer” system
3. Addressing the lack of transparency

Projects:

• Working to pass the Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018) into law. This bill would:
• Establish an electronic prior authorization (ePA) program and require MA plans to adopt ePA capabilities;
• Increase transparency around MA prior authorization requirements and use; and
• Standardize and streamline the prior authorization process for routinely approved items and services.
• Submitting comments to the Centers for Medicare Services (CMS) Medicare Advantage (MA) Request for Information (RFI) on prior authorization in post-acute care. This RFI was a direct result of AAPM&R educating CMS on this issue in these 2021 comments.
• Submitting a Freedom of Information Act (FOIA) request to the Centers for Medicare Services (CMS) requesting the proprietary guidelines used in Medicare Advantage programs.
• Successfully advocating that the American Medical Association (AMA) House of Delegates (HOD) enact AMA policies to make various improvements to the prior authorization process. Thank you to our PM&R delegates! Read more here.

Learn more about our work in Prior Authorization Reform and other important Academy priorities.

Workforce Capacity

• Advocating to Congress for:
• 1400 Medicare-funded GME seats, specifically supporting the Resident Physician Shortage Reduction Act of 2021 (H.R. 2256/S. 834).
• Foreign-trained physicians to remain in the U.S. upon completing residences if they practice in areas with doctor shortages, specifically supporting the Conrad State 30 and Physician Access Reauthorization Act (H.R. 3541).

Learn more about our efforts in Workforce Capacity.

Coding and Documentation Simplification

• Advocating to CMS for streamlined Evaluation and Management coding as developed by the AMA Current Procedural Terminology (CPT) Panel, to decrease documentation burden by reducing the number of key documentation components.
• Educating members about payer documentation requirements to minimize audit risk while minimizing burden to the greatest extent possible.

Access our Coding and Reimbursement resources.

Pandemic Preparedness

• Advocating to Congress and the Administration for specific policies including:
• Regulatory waivers
• PPE supply and access
• Telehealth expansion and reimbursement
• Medical liability flexibility, specifically supporting the Coronavirus Provider Protection Act (H.R. 3021)

Explore the ways AAPM&R is supporting your needs during this pandemic and the Long COVID/PASC crisis.

Other Administrative Burdens

• Opposing the proposed IRF Review Choice Demonstration (RCD), which would subject selected IRFs to 100% pre-claim or post-claim review of their Medicare claims. Click here for more background on AAPM&R’s participation in this issue in 2021.
• Reforming the post-acute care audit process to reduce inpatient denials and increase access to rehabilitation.
• Expanding reimbursement for telehealth services, including audio-only telehealth, beyond the pandemic.
• Repealing or modifying the Appropriate Use Criteria (AUC) program.
• Flexibility and physician deference in post-acute care:
• Expanding the therapies that qualify under the three-hour rule
• Expanding the list of qualifying conditions that count toward the 60% rule
• Counting acute hospital observation days towards the SNF three-midnight rule (Improving Access to Medicare Coverage Act of 2021, H.R. 3650/S. 2048)

Learn more about our efforts to reduce Administrative Burden.