CMS must do more to improve MA prior authorization, payment issues, policy experts say

The rule issued last month from the Centers for Medicare & Medicaid Services reduces wait times to within one week for many standard Medicare Advantage prior authorization decisions. It does not go far enough, said Nicole Fallon, VP of managed care public policy or LeadingAge, noting that prior authorization decisions should only take a couple of hours. She and her colleague, Mollie Gurian, VP of home-based public policy for LeadingAge, pointed out that they also are pushing for MA prior authorizations to cover patients across their post-acute care journeys, including 30-day home health episodes. They also are striving for payment adequacy, as many MA plans pay only 60% or 80% of Medicare fee-for-service rates. Among other changes, they are hoping for the shedding of the statutory noninterference clause that prohibits CMS from telling plans how to pay. Despite the challenges ahead in reforming MA, Fallon and Gurian believe MA has introduced positive healthcare reforms, such as supplemental benefits, and CMS and lawmakers are asking the right questions to continue to improve the private Medicare benefit.

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