Former Medicare Staff Pen Prior Authorization Reforms Plea

February 21, 2025

Former Medicare Staff Pen Prior Authorization Reforms Plea

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BY Nicole Fallon

Former CMS leaders argue that further reforms of the Medicare Advantage prior authorization process are needed, citing data showing that plans are still not getting it right–and one result may be delays in access to critical care

Former deputy administrator and director of the Center for Medicare at the Center for Medicare and Medicaid Services (CMS), Meena Seshamani, and former CMS Senior Policy Advisor on Medicare Advantage (MA) and Medicare Part D, Molly Turco, reflected in a Health Affairs article on the work they have done to clarify prior authorization practices in MA, outlined that problems persist and further reforms are necessary.

Much of what is laid out in the article aligns with issues LeadingAge identified and communicated to the authors during their CMS tenure, such as prior authorizations are: “1) barriers to access for medically necessary care, 2) a huge administrative burden on the U.S. health care system, and 3) [are having] negative market impacts.”

These Medicare and MA experts argue there is “wide consensus for change” and encourage current policymakers to finalize the Calendar Year 2026 MA policy rule (see LeadingAge’s comments on the rule here) along with pursuing other bipartisan actions. The article includes some key takeaways:

Initial appeals are overwhelmingly successful. When prior authorization denials are appealed, the plans overturn roughly 80% of their own denials.
Paperwork not medical necessity is frequent cause of denials. Plans often suggest insufficient documentation by the providers led to the denial, but the authors point out that means the services are being denied not because of medical necessity but for paperwork reasons.
Plans are increasing their spending on supplemental benefits vs. core Medicare benefits. “The portion of the government payments to plans directed towards core Medicare Part A and Part B benefits has decreased.” Supplemental benefit spending by plans has nearly doubled in the past 10 years.
MA plan audits suggest high-cost services should be prioritized for oversight. Providers and consumers feel appropriate post-acute care is being denied while plans think they made the correct decision. Some plans have suggested other plans non-compliance gives them a “financial edge.” The challenge is many plans have outsourced their prior authorization work to third parties. They believe new data collection efforts will give CMS a better view into whether certain services (e.g. Skilled Nursing Facility services) are being denied more often by some plans than others.