On June 28, 2022 the House Committee on Energy & Commerce Subcommittee on Oversight and Investigations held a hearing to examine the quality of care provided to the 27 million seniors enrolled in Medicare Advantage plans. The committee addressed issues related to access to care, quality of care, and equality of care among different demographics of patients. We summarize key highlights from the hearing related to prior authorization and utilization management in this blog post. 

THE PROBLEM(S)

IMPROPER DENIALS DELAY CARE

Assistant Inspector General of the Department of Health and Human Services, Erin Bliss, addressed improper barriers to access for enrollees of Medicare Advantage. She pointed to an HHS study that found 18% of Medicare Advantage enrollees (in the study) were outright denied care that they should have received, and 13% were required to seek prior authorization and were still improperly denied care. Reasons for denials included: 

• Medicare Advantage Plans are allowed to use internal clinical criteria that go beyond Medicare coverage rules in some circumstances. 
• CMS guidance on internal clinical criteria is lacking detail. 
• Claims were denied citing documentation that was not actually required, or documentation that was already submitted. 
• Claims were denied that should not have been – according to an OIG study released in April using data from one week in 2019, 75% of prior authorization denials included in the study were later reversed. 

The OIG report also noted that physician-administered injections, such as those for pain management, are among the most routinely denied services because they are subject to extra scrutiny. 

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FEW DENIALS ARE APPEALED 

The OIG found that only ~1% of denials were appealed. 

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PRIOR AUTHORIZATION PLACES A BURDEN ON PHYSICIANS, IMPACTS PATIENT CARE

As several attendees stated during the hearing, prior authorization places a burden on physicians, their staff, and negatively impacts patient care. Rep. Kim Schrier (D-WA) cited  the AMA’s most recent survey which found 40% of practices employ staff to work exclusively on prior authorizations. She also cited the impact on patient care – 34% of physicians surveyed by the AMA reported prior authorization has led to a “serious adverse effect” on patients and their care. 

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INCREASING STEP THERAPY REQUIREMENTS ARE NOT BEST FOR PATIENTS

Rep. John Joyce (R-PA) noted the increasing burden created by step therapy requirements. This “fail first” approach can cause unnecessary delays in care, instead of allowing physicians to determine the treatment that is best for their patients. Rep. Joyce noted that Medicare fee-for-service does not use step therapy protocols and covers products under part B if they are reasonable and necessary. While step therapy was not a primary issue being considered during this hearing, Ms. Bliss indicated the OIG would consider new research to investigate the issue. 

THERE IS A SCARY LACK OF DATA ON PRIOR AUTHORIZATIONS AND PATIENT IMPACT 

Rep. Scott Peters (D-CA) Vice Chair summed up the dearth of data pervasive in the hearing, stating “the government has failed to appreciate the foundational role of good data in decision-making.” While the OIG study relied on heavily during the hearing was directional in uncovering substantial issues with MA plan administration, some pointed to the sample size of the study being small as it was isolated to a couple hundred submissions during a single week in 2019. Further, data points related to the impact of denials and delays on patient care are simply not being tracked. 

SOLUTIONS

Proposed solutions were largely centered around the current Seniors' Timely Access to Care Act before Congress, and the recent adoption of “gold-carding” in Texas. 

• Electronic prior authorizations – as called for in the Seniors' Timely Access to Care Act, the committee agreed this is an important step in reducing physician burden and avoiding denials caused by human errors such as not seeing paperwork in a file, and enabling real-time decisions. Learn more about the state of electronic prior authorizations here. 
• Data and accountability – the Seniors' Timely Access to Care Act requires payers to report their use of prior authorization including rates of approvals or denials to more easily surface potential issues. The Act also requires payers to provide physicians with a reason for denial. 
• Gold-carding – this practice, currently being tried in Texas, would enable physicians with a history of good practice and reimbursements to bypass prior authorization requirements. 

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