Democratic Senate and House committee leaders urge CMS to strengthen oversight of MA plans, citing concerns about inappropriate delays and denials of care, as well as marketing abuses that compromise access to essential services for seniors and people with disabilities.
EviCore and similar companies prioritize profitability in their prior authorization processes, often resulting in rigid and outdated guidelines that lead to inappropriate denials and delays in patient care, despite claims of improving healthcare quality and safety.
Delays in patient care and harmful outcomes due to prior authorization have prompted calls for reform and legislative action.
Physicians emphasize that prior authorization delays significantly hinder timely and effective cancer treatment, often resulting in worse patient outcomes and increased emotional distress.
Cigna Group is scaling back its Medicare Advantage offerings in eight states, affecting around 5,300 members, as it prepares to sell its Medicare business for $3.3 billion and focus on expanding its Evernorth Health Services segment.
Experts question whether Medicare Advantage is more affordable than traditional Medicare, noting that high out-of-pocket costs and prior authorization hurdles in Medicare Advantage plans may contribute to affordability concerns.
While Congress struggles to address prior authorization issues, states are enacting more stringent regulations, with 23 states passing over 43 related bills recently, aiming to streamline processes and reduce administrative burdens on providers and patients.
The prior authorization process for specialty drugs delays patient access to necessary treatments, creating administrative difficulties for both physicians and specialty pharmacies.
In 2022, there were 46 million prior authorization requests, up from 37 million in 2019, with 10% of denials appealed and 83% of those appeals overturning the initial denial, according to research.
Centene will exit the Medicare Advantage market in six states in 2025, affecting about 3% of its membership, while maintaining presence in other markets, with CVS and UnitedHealth Group also active in these regions.
Nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services, according to research.
Seven insurers are exiting the Medicare Advantage or Part D markets in 2025.
Starting October 1, UnitedHealth Group’s new “gold card” program will exempt qualifying physician practices from prior authorization requirements for certain services.
Protesters were arrested outside UnitedHealthcare headquarters for alleged denial of care, while the company contends that it has resolved issues and prioritizes employee safety amid recovery from February’s cyberattack.
Evolving prior authorization regulations are being hailed for enhancing transparency and efficiency, but further legislative efforts are said to be needed to address gaps and reduce administrative burdens.
A Wall Street Journal analysis found that from 2018 to 2021, Medicare Advantage insurers claimed thousands of questionable or false diagnoses, leading to $50 billion in extra taxpayer payments without corresponding care.
Rep. Marsha Blackburn (R-TN) put out a press release regarding the reintroduction of the Improving Seniors’ Timely Access to Care Act, urging colleagues to support modernizing and streamlining the prior authorization process.
Rep. Earl “Buddy” Carter (R-GA) discussed Congress’s inability to pass the Improving Seniors’ Timely Access to Care Act and cited strong insurance industry lobbying as a major obstacle.
Congress reintroduced a bill to streamline Medicare prior authorization processes and prevent rollbacks of Biden administration reforms.
Medicare Advantage enrollees report treatment denials and delays in payment, leading to harmful outcomes in healthcare.
GAO found scant state oversight of plans’ prior authorization decisions. It found that none of the states sampled scrutinized a representative sample of claim denials or leaned on data to determine “the appropriateness of the full scope of plans’ prior authorization decisions.”
Medicare Advantage (MA) insurers that impose prior authorization requirements on doctors in accountable care organizations (ACOs) should have to get them pre-approved by CMS, Sen. Sheldon Whitehouse (D-R.I.) said Wednesday.
Value-based care, increased competition and a standardized claims process all could help the problems in the U.S. health care system that are piling on to physician burnout, patient outcomes, and growing costs, said three experts who testified in Congress.
A recent voluntary, national survey by Premier shed new light on denied claims.
On April 4, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year (CY) 2025 Medicare Advantage (MA) and Medicare Part D Policy and Technical Changes final rule (“Final Rule”), which included revisions to the regulations governing how MA organizations and Part D plan sponsors (referred to collectively throughout as “issuers”) compensate agents, brokers and third parties.
The Centers for Medicare and Medicaid is evaluating whether it needs to take further steps cracking down on health insurance companies’ prior authorization requirements.
The federal government is addressing delays caused by insurers requiring prior authorization before medical professionals can provide some care. Experts say speeding up the process can aid patients and cut healthcare costs.
As prior authorization has spread, delays in care have become normalized.
The new CMS rule aiming to streamline prior authorization signals a major step forward for primary care, but the process could still use some improvement, according to experts.
Advocates for quicker care joined the organizations responding to new Medicare rules that aim to speed up the prior authorization process and increase data sharing in medicine.
New federal rules requiring health insurers to streamline requests to cover treatments are being hailed as a good first step toward addressing a problem that’s increasingly aggravated patients and doctors.
Doctors are cheering the new federal rule announced Wednesday which will speed up health insurance company decisions on whether to authorize or deny medical care or treatments for millions of patients.
Hospitals and other healthcare providers hailed a newly published final rule designed to improve prior authorization and the electronic exchange of health information.
Physicians groups on January 17 hailed a new federal rule requiring health insurers to streamline and disclose more information about their prior authorization processes, saying it will improve patient care and reduce doctors’ administrative burden.
A federal rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments. The move was welcomed by hospital and physician groups, as well as by members of Congress from both parties.
The Centers for Medicare and Medicaid Services finalized the CMS Interoperability and Prior Authorization Rule on Wednesday. CMS said the rule will improve the prior authorization process and save about $15 billion over 10 years.
The Biden administration moved Wednesday to force insurance companies to give specific reasons for denying coverage, and to speed up the pre-approval process in general.
U.S. President Joe Biden’s administration on Wednesday finalized a rule requiring health insurers to set time targets for the prior authorization process for patients seeking approval for medical services under government-backed insurance plans.
The Biden administration on Wednesday finalized requirements to streamline the process for doctors and patients seeking health insurance approval for medical care and treatments.
Payers have new deadlines to issue prior authorization decisions — 72 hours for urgent requests and seven days for non-urgent ones.
Under a final rule released today, impacted payers will be required to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests.
A final rule from the Centers for Medicare & Medicaid Services (CMS) setting time limits and other requirements related to prior authorizations drew generally positive reviews Wednesday from healthcare organizations, although some expressed concerns about specific provisions.
To combat growing criticism of prior authorization delays by payers, Centers for Medicare & Medicaid Services finalized a rule Wednesday that requires health plans to send prior authorization decisions within three days for urgent requests and seven days for standard requests starting in 2026.
