Democrats Question Oz on the MEDICARE previous authorization pilot

Diving brief:

• Democrats arouse concerns about a new CMS pilot program testing the preliminary authorization requirements, which means that patients obtain the approval of their health plan before receiving certain services, in traditional health insurance.
• The pilot, who is expected to come into force next year, will add new administrative formalities to the federal insurance program that could delay care and worsen the results, 17 Democrats in the Chamber wrote in a letter to the administrator of the CMS, Dr. Mehmet Oz.
• The letter, directed by representatives Suzan Delbene, D-Wash. And friend Bera, d-Calif., Requests more information on how the pilot will be implemented, which services will be subject to prior authorization, how requests for care will be examined and how regulators plan to avoid inappropriate refusals for health insurance beneficiaries.

Diving insight:

The CMS ‘Innovation Center announced at the end of June that it planned to test new previous authorization requirements in traditional health insurance in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.

The Government will contract with private companies, including medicare plans, to set up previous authorizations for certain services, including skin and tissue substitutes and certain knee surgeries.

Insurers defend previous authorizations as a precious strategy to limit unnecessary health expenses. But the use management tool is also a major administrative charge source for providers and can delay or prevent care for patients, which leads in certain cases to worst health.

Traditional health insurance only requires prior authorization in rare cases, so that the pilot – and the fact that his announcement coincided with the administration of Trump which was moving to reduce previous authorizations in other areas – immediately raised red flags for certain experts.

In June, the administration obtained promises of major insurers to reduce previous authorizations, especially in private mastery plans where criticisms say that the tool was crawling.

In 2018, the office of the Inspector General of the HHS noted that 75% of the previous authorization requests refused in MA had been canceled during the appeal. Four years later, another HHS OIG report found that the MA plans were often more restrictive in their use of the prior authorization than in the coverage rules of Medicare.

Now, a group of democrats seeks answers to Oz to explain why the administration is trying to weave previous authorizations in traditional health insurance and how it plans to do so.

“The use of prior authorization in Medicare Advantage shows us that, in practice, [the proposal] Probably limit access to beneficiaries to care, will increase the burden of our already overloaded staff on health care and create perverse incentives to write profits on patients, “the legislators in the Monday letter wrote.

In particular, legislators said they were fearing that the preventing administration to contract companies as I plan to manage demonstrations, especially since companies can have financial incentive in the model to reduce care as much as possible. The entities contracted are reimbursed by sharing any economy which they generate from the restriction services, necessarily or not.

Likewise, the model will not be voluntary for providers participating in Medicare in the six states of the test model, creating an “involuntary burden”, indicates the letter.

In a statement parallel to the publication of the model, Oz said that the program should protect the beneficiaries of Medicare from “unnecessary and often expensive procedures”.

Refusals of care will be examined by a clinician and services that will present a “substantial” risk for patients if they are delayed will be excluded from the model, according to a CMS website on the program. It is not clear how the CMS plans to define these services.

The legislators asked Oz to answer their questions in early September.