Hospitals and suppliers say federal regulators ought to search authority from Congress to require Medicare Benefit plans to pause prior authorization necessities throughout future public well being emergencies.
The Facilities for Medicare and Medicaid Companies allowed MA plans to loosen up or waive prior authorization necessities for affected person transfers to post-acute care services throughout 2020 because of the COVID-19 public well being emergency. However because the PHE continued, many plans reinstated necessities for plan 12 months 2021. CMS’ proposed rule says hospitals have informed the company that extra affected person switch flexibilities from MA plans might ease mattress shortage.
CMS requested data in a current proposed rule concerning the affect of MA plans’ prior authorization necessities for affected person transfers on hospitals’ care and time administration capabilities throughout a public well being emergency.
Publish-acute care services have been key to pandemic response, offering specialised care to sufferers who’re sick with—and recovering from—COVID-19, the American Hospital Affiliation emphasised in a remark letter to CMS submitted Monday.
However insurers’ prior authorization insurance policies usually result in delayed discharge, that means suppliers should use restricted acute-care assets on sufferers that might have benefited from care elsewhere, AHA stated. This has triggered further pressure on hospitals through the PHE, when many hospitals across the nation have operated at full capability and even delayed non-essential care throughout COVID-19 surges.
“We acknowledge that prior authorization is a device that, when used appropriately, might help align sufferers’ care with their well being plan profit construction and facilitate compliance with scientific finest practices. Nevertheless, its misuse and utility throughout a PHE has negatively affected affected person care and the supply system’s response to a world well being disaster,” AHA stated.
AHA stated plans’ inconsistent use of prior authorization waivers have made operations significantly tough for post-acute care suppliers like inpatient rehabilitation services and long-term care hospitals, that are typically excluded from prior authorization waivers.
The American Medical Rehabilitation Suppliers Affiliation, which represents inpatient rehabilitation services, echoed this in its personal feedback to CMS.
AMRPA surveyed 475 inpatient rehab services throughout the USA final August and located that about 52% of preliminary requests for affected person transfers into inpatient rehab have been denied. Suppliers and sufferers needed to wait a median of two.59 days for a denial from an MA plan, and a pair of.49 days for an approval. The survey encompassed 30,926 pointless days that sufferers spent in acute-care hospitals when suppliers believed post-acute care would have been acceptable.
The info exhibits MA plans are inappropriately limiting inpatient rehab facility entry by prior authorization, AMRPA contends. In accordance with the group, MA beneficiaries represented solely 20% of Medicare inpatient rehab admissions in 2019, regardless of representing about 36% of all Medicare enrollees. When prior authorization waivers grew to become widespread firstly of the pandemic, MA and conventional Medicare beneficiaries’ admissions to inpatient rehabs grew to become extra proportional, AMRPA stated.
“The outcomes of this survey demonstrates the urgent want for coverage makers to take long-overdue steps to curb prior authorization practices and guarantee Medicare beneficiaries obtain the care they want and are entitled to,” stated Anthony Cuzzola, chair of the AMRPA board of administrators and vice chairman of the Hackensack Meridian Well being JFK Johnson Rehabilitation Institute. “In my hospital, and in these I converse to across the nation, we see sufferers needlessly ready for choices—and discharged to inappropriate settings because of prior authorization.”
Going ahead, CMS ought to ask Congress for the authority to require MA plans to droop prior authorization necessities throughout future public well being emergencies, each organizations stated of their feedback. CMS also needs to make certain denials are reviewed by acceptable specialists, enhance guidelines and enforcement round timelines for determinations, and extra, AMRPA stated.
The Regulatory Reduction Coalition, which consists of fourteen supplier commerce associations, additionally wrote to CMS asking for broader consideration to prior authorization points past simply hospital overcrowding. CMS ought to set up an digital and real-time prior authorization course of for federal packages, decrease prior authorization use for routinely authorised gadgets and providers, improve transparency round prior authorization necessities and extra, the coalition stated.
For its half, insurance coverage lobbying group AHIP stated in its personal feedback—on the request for data—that prior authorization is a helpful device to guard sufferers however really helpful CMS to proceed offering MA plans with prior authorization flexibilities throughout COVID-19.