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CMS Responds to Roe-Bera Letter on Improving Prior Authorization in Medicare Advantage

As we reported last fall, following ASCRS and medical community advocacy, Reps. Phil Roe, MD (R-TN), and Ami Bera, MD (D-CA), drafted a letter to CMS requesting that the agency “improve how prior authorization works under MA plans.” In the letter, the Congressmen—and more than 100 of their colleagues in the House—expressed their concern that patients may be encountering barriers to timely access to care that are caused by onerous and often unnecessary prior authorization requirements, such as step therapy for Medicare Part B drugs.

Recently, CMS Administrator Seema Verma sent a response letter to Rep. Roe to address his and his colleagues’ concerns. In her letter, Administrator Verma reminds the Congressman that MA plans are allowed to have prior authorization requirements that are consistent with original Medicare coverage criteria, but they are also “expected to annually review their prior authorization requirements so that they are up-to-date with current clinical criteria and Medicare's local and national coverage decisions.” She tells Rep. Roe that MA plans should be transparent about prior authorization policies and provide adequate notice to providers and enrollees of prior authorization requirements. MA plans should specify any coverage restrictions, including what information is needed when a provider submits a prior authorization request.

Administrator Verma goes on to say that, “Plans must render coverage decisions as expeditiously as an enrollee’s health condition requires within the applicable adjudication timeframes,” and assures the Congressman that CMS will take his suggestions under consideration.

ASCRS continues to advocate for regulatory relief, as well as removal of barriers to specialty care, including the use of prior authorization in MA plans, which is burdensome for physicians and can delay patient care. To read Administrator Verma’s letter in its entirety, click here.

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