Press ReleasesBLOG POST: CMS to MA plans, relax prior auth requirements

CMS is urging Medicare Advantage plans to relax or waive prior authorization requirements for moving patients from general acute-care hospitals to post-acute care settings like long-term-care hospitals, inpatient rehabilitation facilities, skilled nursing facilities and home health agencies.

The request comes amid a surge in COVID-19 cases and rising hospital occupancy, which the agency hopes to relieve with the change.

“The ability of hospitals to transfer patients to appropriate levels of care without unnecessary delays or administrative burdens is critical to ensuring that hospitals have open acute-care beds to treat patients requiring emergent care,” the agency said in an Aug. 20 letter.¹ It also reminded plans that any flexibility granted by MA plans “must be uniformly provided to similarly situated enrollees.”

Although MA plans are not required to follow the same requirements or policies as original Medicare for establishing medical necessity, they may not set requirements that are more stringent.

While many payers relaxed prior authorization requirements in 2020, some have begun reintroducing them for certain procedures and services.² Meanwhile, payers have been urging providers to begin using electronic prior authorization, which can reduce delays in care while maintaining the benefits of prior authorization, including enhanced patient safety and use of evidence-based care.^{2, 3}

In its request, CMS reminded MA plans that they may waive or relax plan prior authorization requirements at any time to ease access to services, regardless of whether there is a current public health emergency.

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^References

1. COVID-19 Flexibilities Reminder. CMS. Aug. 20, 2021. https://images.magnetmail.net/images/clients/AHA_MCHF/attach/2021/August/HPMSMemoCOVID_19FlexibilitiesReminder08202021.pdf
2. Waddill, K. CMS asks Medicare Advantage plans to relax prior authorizations. HealthPayerIntelligence. Aug. 24, 2021. https://healthpayerintelligence.com/news/cms-asks-medicare-advantage-plans-to-relax-prior-authorizations
3. AHIP survey: Prior authorization grounded in clinical evidence and selectively used. AHIP. June 9, 2020. https://www.ahip.org/ahip-survey-prior-authorization-grounded-in-clinical-evidence-and-selectively-used/