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Congress seeks to improve MA prior auth process

by Yvonne Tso, PharmD, MBA

The House of Representatives is proposing legislation (H.R. 3173) to streamline prior authorization requirements under Medicare Advantage (MA) plans. The proposed bill aims to modernize the prior authorization process in MA by:

  • Establishing an electronic prior authorization process that would streamline approvals and denials

  • Requiring the Department of Health & Human Services (HHS) to establish a process for “real-time decisions” for items and services that are routinely approved

  • Improving transparency by requiring MA plans to report to the Centers for Medicare & Medicaid Services (CMS) on the extent of their use of prior authorization and the rate of approvals or denials

  • Encouraging plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians

  • Establishing national standards for clinical documents that would reduce administrative burdens for health care providers and MA plans

  • Requiring beneficiary protections that would ensure the electronic prior authorization serves seniors first

Whether the final version of the proposed bill will contain all of the above and become law for Medicare is unknown for now. However, it is not too late to do a check-up on your organization determinations and appeals processes to ensure you are not among those in a report published by the Office of the Inspector General (OIG) that found MA organizations (MAO) sometimes delayed or denied their enrollees’ access to services even when the requests met Medicare coverage rules[1].

What should one look for in this “check-up?

  • Do not deny services covered by Original Medicare.

  • When denials are reversed upon reconsideration, identify the initial denial reason(s) to assess if the decision-making processes are consistent and appropriate. Follow National Coverage Determination (NCD) or Local Coverage Determination (LCD) guidelines. Keep up with changes in guidelines (e.g., criteria for continuous glucose monitoring, expanded telehealth coverage). If and when an enrollee has to appeal to gain access to medically necessary care, delay already occurred and the enrollee’s health may be in peril.

  • To err is human but there should be systematic ways to detect, prevent and correct frequent or repeat manual review errors.

  • Look through existing medical records before asking for documentation from the provider, another potential source of delay.

  • When an error is discovered in a mock audit, conduct a thorough root cause and impact analysis because it may not be a one-off instance or human error. It is important to identify the point(s) of failure to avert recurrences.

Below are some common findings from historical CMS audit reports and the OIG study.

  • MRI and CT scan denials because an X-Ray is not performed as a pre-requisite or conservative treatment has not been tried.

  • Admission to a skilled nursing facility (SNF) should be approved as opposed to a lower level of care if the enrollee needs medical supervision and physical and occupational therapy or if the enrollee has multiple ongoing conditions necessitating skilled nursing care.

  • Do not overlook referrals by a participating (PAR) network provider to a non-PAR provider, as CMS considers that plan directed care[2].

  • A provider’s network status should be correct to avoid time-consuming consequences when a PAR provider is inadvertently coded as non-PAR.

  • Provider services are submitted in multiple lines; when denying a miscoded procedure, make sure other line items are not denied inadvertently.

  • When a contract or fee schedule is amended or updated, respectively, make sure the change is timely implemented in the system to avert adjudication errors in fees and pricing.

  • A provider may have multiple taxpayer ID or NPI; cross-referencing them can avoid mistaken identities and denials.

Conducting mock audits is time-consuming. Retaining an external auditor adds value with objectivity and perspectives from the MA industry and recommendations for best practices. Integritas Medicare has long-standing experience and expertise in conducting mock audits on all aspects of the Medicare Advantage program. If you think diagnostics can enhance your procedural health, feel free to contact us at 415-596-5277 or

[1] [2] Medicare Managed Care Manual Chapter 4 Section 160

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