The prior authorization process was brought in to reduce medical administrative waste and prevent unnecessary medical care. Several years one it still continues to be a bone of contention between the provider community and insurance companies. Reforms under the current administration seek to simplify the PA process and eliminate practices that may result in patients from accessing much needed medical care. But is it enough?
On April 5th The Centers for Medicare and Medicaid issued its final Part D 2024 MA rule.
- Prior authorization for treatment is held valid till the course of treatment is necessary to avoid care delays.
- A 90 day transition time is available for patients who decide to switch MA plans during the treatment. The new plan cannot mandate PA for the active treatment.
- MA plans must revise their coverage guidelines to intersect with Medicare coverage guidelines.
Unfortunately, some key consideration are unaddressed. The timeframes for determining prior authorization requests can be further shortened to prevent care delays and the strain on administrative staff to follow up on PA requests. Retroactive denials should be prevented to ensure medical claims are appropriately reimbursed once the prior authorization process is completed and approval given. Failing to do so results in denials that could’ve been prevented in the first place.
Also, the provider community would greatly benefit if authorization requests are automatically approved if a payer defaults on approval deadlines.
What are your thoughts?
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