While prior authorization has a legitimate role under Medicare Advantage, the practice has expanded to the point where it negatively impacts care. This aspect of MA needs to be right-sized, possibly through legislation, nursing home leaders said.

American Medical Association president Dr. According to Bruce Scott, nearly 90% of physicians, including those who care for nursing home patients, said one or more of their patients had suffered serious harm due to delays in obtaining prior authorization ( AMA ).

“For 24% of these physicians, this delay resulted in hospitalization, permanent disability or death, which harms patients,” Scott said at Sanford Health’s Rural Health Summit on Tuesday. Scott’s panelists included Zach Shamberg, president and CEO of the Pennsylvania Health Care Association (PHCA), and Ceci Connelly, president and CEO of the Association of Community Health Plans (ACHP). The panel was moderated by Corey Brown, Sanford Health’s senior vice president of government affairs.

Leaders said Congress and federal agencies need to get involved by adding transparency to prior authorization denials so nursing homes can properly appeal denials. Legislation should require MA schemes to use the latest form of technology to transfer documents required for prior authorizations; in other words, no more faxes.

Legislation blocking previous authentication requests

Approximately 12 states have already implemented prior authorization reform. pending legislation Scott said it’s in 13 other states.

“If health plans aren’t willing to do this voluntarily, legislators will force it on them,” he said.

Congressional or other government intervention in healthcare has historically stifled innovation because of little understanding of the nuances of different markets and different players in the MA space, Connelly said. But in terms of pre-clearance, he said it is first and foremost about safety.

Some MA health plans, including Sanford Health Plan and Geisinger Health Plan, receive fewer prior authorizations than larger national plans, he said. And if prior authorization is requested, patients and operators get a “yes” in real time to about 85% of requests through the use of artificial intelligence, at least for Geisinger members in Central Pennsylvania.

ACHP is a national organization with nonprofit, community-based member health companies in 40 states and Washington, DC.

“I encourage everyone out there listening to find the right partners to work with you to provide the right care on the front end, and we’re going to see these issues really start to diminish everywhere,” Connelly said.

Still, he said MA has reached a point where recalibration more generally is necessary because “public giants are rightly reviewed Senate Finance Committee, Centers for Medicare and Medicaid Services (CMS) and the Inspector General of Health and Human Services (HHS OIG).

“What’s going on with risk adjustment, coding, marketing practices, etc. really questions the reasons for getting involved in this program,” Connelly said of MA. “What happens to nonprofit community plans that operate on a 1% or 2% margin if they’re lucky? “We are at a very important juncture in public policy and the future of this public-private partnership.”

How previous authentication was tied to staff shortages

Prior authorizations are also a major source of burnout among doctors, with the average doctor spending 12 hours a week filling 43 prior authorization requests, Scott said. Brown added that 95% of physicians cite prior authorization issues as a cause of burnout; He said the team at Sanford struggles with previous authorizations every day.

“A 2023 survey found one in five positions said they were fed up and considering retiring or quitting within the next two years…add that to your workforce shortage,” Scott said.

Stating that Cigna rejected 300,000 pre-authorization requests within a two-month period, Scott drew attention to concerns about artificial intelligence and pre-authorization requests.

“If you’re working 24 hours a day, seven days a week, that’s 1.2 seconds per prior leave request,” Scott said of the Cigna example. “There are multiple states where review of actual clinical data is required. Over 90% of prior authorizations are ultimately approved, so even from a health plan perspective, this is a waste of resources.”

The AMA met with large MA plans in 2019 and asked them to voluntarily fix prior authorization issues, but said those requests had increased in frequency and were for smaller services, including $10 nasal sprays and routine CT scans.

“Pre-clearances have grown so much, they have gotten out of control. We’re not advocating elimination, but when over 90 percent of the 300,000 rejections are ultimately overturned by those who appeal, you have a broken system,” Scott said.