CMS Takes Aim At Prior Authorization Requirements In Medicare Advantage

Home Health Care News / By Audrie Martin

The Centers for Medicare & Medicaid Services (CMS) is proposing new limits on Medicare Advantage (MA) plans regarding prior authorization, utilization management, coverage decisions and the use of artificial intelligence (AI). These proposed changes aim to address the barriers to accessing care identified by CMS.
 
Data reported to CMS by MA plans show that, on average, these plans overturn 80% of their claim denial decisions when appealed. However, less than 4% of denied claims are actually appealed, indicating that many more denials could potentially be reversed through the appeals process. This data suggests that MA enrollees may not be receiving necessary care. 
 
CMS is actively working to mitigate inappropriate prior authorization and other utilization management practices that limit access to care, create system-wide burden and negatively impact health care providers. 
 
CMS’ utilization management audits, conducted throughout 2024 and into 2025, have informed the proposals outlined in this rule. 
 
“We continue to hear from people enrolled in Medicare Advantage who are having difficulty accessing the care they need and are entitled to. CMS remains focused on removing these barriers,” Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, said in a statement. “No senior or person with disabilities on Medicare should have to face challenges in navigating options, affording lifesaving medications prescribed by their doctor, or receiving the inpatient or rehabilitation care they need to recover.” 
 
Some health plans have already begun to undo some burdensome prior authorization requirements…

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