The California Medical Association (CMA) voiced support for federal reforms proposed by the Centers for Medicare and Medicaid Services (CMS) that would help ensure payors implement timelier and more transparent patient-centered prior authorization programs and allow physicians to spend more time with their patients.

CMA submitted comments to CMS lauding the agency for the meaningful reform in its second proposed rule that would improve prior authorization in many public programs, including Medicare Advantage, Medicaid, the Children's Health Insurance Program (CHIP), and qualified health plans on the federally-facilitated exchanges (not the California Exchange, Covered California). However, CMA also urged CMS to adopt improvements to strengthen the rule. 

The proposed rule’s prior authorization reforms include:

• Increase public transparency of prior authorization processes, including aggregated information on payor approvals, denials and overturned decisions, as well as the response times. (CMA is also urging more detailed information be reported and published on the CMS website.)
• Require payors to establish a uniform electronic prior authorization system to reduce administrative burdens and costs for both plans and physicians.
• Require all payors under the rule to use clinically-based evidence to make decisions and to share that information with physicians.
• Mandate payors to establish Utilization Management Committees with physicians. 
• Establish deadlines for prior authorization decisions. (CMA recommends shorter deadlines – 24 hours for expedited requests/48 hours for standard requests – to prevent adverse health outcomes for patients.)
• Require payors to provide reasons for denials. (CMA is urging CMS to require more detailed responses.)
• Restrict retroactive denials.
• Incentives for payers to adopt a “gold-carding” or TSA pre-clearance type of program that exempts physicians with a history of high approval rates.

CMA also urged CMS to apply the proposed rule to all health plans and drugs that are part of a medical benefit and to establish stronger oversight and enforcement mechanisms.

CMA also told CMS that we oppose prior authorization as a Quality Payment Program measure in the Medicare fee for service program.

CMA  previously joined the American Medical Association and more than 100 physician groups to highlight their support for the first set of  reforms proposed for Medicare Advantage plans.

Share Your Story

CMA is encouraging physicians whose practices and patients have been negatively impacted by prior authorization to share their stories. By adding your voice to the call for prior authorization reform, you can help ensure that patients receive the care they need — when they need it.