American Academy of Ophthalmology Urges CMS to Address Prior Authorization, Other Burdens in Medicare Advantage
In a comment letter submitted to the Centers for Medicare and Medicaid Services (CMS), the American Academy of Ophthalmology (AAO), called on CMS to increase oversight and reform prior authorization, step therapy, and medical record requests in Medicare Advantage plans.
In the letter, dated August 26, AAO leadership wrote to Chiquita Brooks-LaSure, Administrator, CMS, addressing concerns with Medicare Advatage and what the Academy calls harmful policies targeting ophthalmology.
Below is the letter in its entirety.
Dear Administrator Brooks-LaSure,
We appreciate the opportunity for public comment on improving Medicare Advantage (MA) in ways that align with the Vision for Medicare and the CMS Strategic Pillars via the Medicare Program; Request for Information on Medicare (CMS-4203-NC) and applaud this Administration’s focus on matters of health equity. As the leading society in ophthalmology with 27,000 members, the American Academy of Ophthalmology (the Academy) seeks to protect sight and empower lives. As the vast majority of our patients are Medicare-eligible we hope to continue working together to ensure MA plan beneficiaries and the providers that serve them have the support needed to achieve the best possible patient outcomes.
Many of the questions posed by CMS in this request for information align with the Academy’s ongoing concerns regarding MA plans based on continued feedback from our member physicians. With additional consideration to the anticipated growth of MA enrollment and findings from the HHS Office of Inspector General (OIG) report “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care” (OIG Report), it is clear that increased federal oversight is urgently needed to mitigate harms and reduce unnecessary burdens already existing within our MA system.
The Academy seeks to utilize this comment opportunity to identify MA-policies systemically harming patients by placing unnecessary administrative burdens on providers, and to suggest changes within CMS authority that ensure MA plans most effectively address our shared health equity concerns. We believe this is best achieved through centering discussion on three major MA-policy issue areas: Prior Authorization, Step Therapy, and Medical Records Requests. Please see each of these concerns detailed below:
Prior Authorization (PA)
Unencumbered prior authorization requirements are threatening access to care for MA beneficiaries; and as more MA plans implement unreasonable PA requirements the potential for adverse patient impact increases. We share many of the concerns for MA beneficiary access to care described by the OIG in this same report. It is clear that oversight actions must be taken now to prevent a growing divide in the care available to MA enrollees versus traditional Medicare enrollees due to challenges with prior authorization.
When MA plans implement unjustified, clinically irrelevant prior authorization protocols, they create unnecessary treatment delays. Most appeals of prior authorization denials are eventually reversed by MA organizations, but that does not reverse the otherwise-avoidable negative impacts from these delays in medically necessary care. In an American Medical Association survey conducted in late 2021, more than one-third of physicians reported that prior authorizations led to a “serious adverse event” for someone in their care.
The Academy fears that MA payers are increasingly applying prior authorization requirements to medically necessary care with minimal clinical basis for doing so. For example, access to sight-saving eye surgery was significantly impeded when Aetna instituted a national prior authorization requirement for all cataract surgeries across all plans, overwhelmingly one of the most common and successful procedures provided by ophthalmologists.
Through the entirety of Aetna’s policy implementation from July 2021 to July 2022, Academy members frequently reported technical problems with Aetna’s PA-request portal; extended wait times to contact plan-representatives; inaccurate ‘duplicate’ PA-denials for second-eye surgeries; and post-claim denials for services that had previously received prior authorization. These accounts support the OIG findings that 18% of denied PA requests meet Medicare coverage and MAO billing rules. Obtaining prior authorizations and responding to PA denials of medically necessary treatment significantly detract from physician-and-staff-availability for direct patient care, averaging 13 hours per week for every AMA-surveyed physician. Unfocused, overlybroad, and overly-burdensome prior authorization requirements increase total costs to the Medicare program, and seemingly brings into question whether PA currently benefits enrollees at all.
We believe CMS could greatly improve the MA program by closely monitoring and enforcing accountability for plans’ PA approval rates, primary reasons for denials, and other datapoints impacting patient outcomes, especially for PA requirements for common procedures routinely found to be medically necessary. We recommend that CMS share that information publicly so that beneficiaries are better informed when choosing an MA plan and so that necessary feedback loops are established between plans and providers. For example, this oversight could quickly determine whether PA denials for a certain procedure are typically due to relevant clinical or medical necessity reasons rather than irrelevant administrative issues, such as inadequate documentation, which would be more efficiently resolved by enhancing coding and documentation education for providers. Medical societies like the Academy already provide this kind of education to member-physicians on a routine basis and would make ideal partners in improving medical record documentation.
Though Aetna repeatedly declined to share any kind of clinical justification for the PA with the Academy throughout its national cataract requirement, we understand that when the payor provided doctors a grace period to respond with the missing documentation deficiencies, the PA denial rate dropped to 2-3%, a rate that is simply too low to be valuable. Since learning that documentation issues were the primary cause of PA denials for cataract surgery, the Academy has amplified efforts to educate our members on proper documentation. By creating transparency and accountability around PA denial metrics; CMS can work in partnership with MA plans and medical associations to address root-causes of barriers to patient care and ensure the highest patient quality outcomes.
We are concerned as well that when MA plans are free to require prior authorization without demonstrating any sort of justification of need for such a policy, other payors notice and follow suit. After one year of dysfunctional implementation negatively impacting both ophthalmologists and patients, Aetna rolled back their cataract surgery PA requirements nationally, except for in Florida and Georgia. Contrary to CMS’s goal to address equity issues in healthcare, the limited nature of this reversal creates disparate access to care for the nearly 400,000 Aetna Medicare Advantage beneficiaries in these states. Humana followed Aetna’s example, announcing its plans for PA requirements for all cataract and YAG capsulotomy procedures in the state of Georgia beginning August 1, 2022; further jeopardizing the sight of an additional 260,000+ MA enrollees.
Unwarranted prior authorization requirements like those imposed on cataract surgery place vulnerable, often disadvantaged MA beneficiaries at risk for delayed or denied medically necessary interventions to preserve or restore deteriorating vision.5 The sight of MA beneficiaries in Florida and Georgia is still unnecessarily being placed at risk by Aetna and Humana’s PA policies, simply by virtue of where these patients live. We urge CMS to exercise the fullest extent of its oversight authority to address our concerns on how currently allowed and accepted prior authorization requirements are worsening existing health equity issues.
Step Therapy
The Academy wants to ensure that beneficiaries enrolled in Medicare Advantage plans continue to have appropriate and timely access to the therapies they need to properly manage their conditions. We are asking that the agency move swiftly to reinstate the step therapy prohibition in Medicare Advantage (MA) plans for Part B drugs as described in the September 17, 2012, HPMS memo Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services
We were disappointed by the recission of this previous standard by the previous administration. Despite CMS’s efforts to place guardrails for patients, reinstatement of step therapy in 2019 resulted in clear cases of patient harm with a wide range of consequences that we have previously detailed to CMS in both written and oral communications. In May 2022, the Academy and a group of other medical associations and patient advocacy groups met with CMS leaders to share examples of the harm caused to patients by step therapy protocols. We followed this meeting with a letter sent to CMS in June 2022 reiterating our concerns (see attached). This letter garnered 79 cosigners, illustrating the broad negative impacts of step therapy on MA beneficiaries.
With Part B drugs necessary for treating some of the most vulnerable Medicare beneficiaries, the allowances made in 2019 for plans to implement step therapy procedures have created a significant health equity issue. Recent analysis of the Medicare beneficiary demographic characteristics shows that MA enrollees are disproportionally lower-income, Black or Latino, and dually enrolled in Medicaid when compared to traditional fee-for-service enrollees. Patients treated under these private for-profit MA plans are being deprived of the same health care that those in fee-for-service receive when MA plans are allowed to use step therapy. As enrollment in MA plans rapidly grows, including Special Needs Plans, the number of patients harmed due to step therapy protocols will continue to increase. The growth in MA plan enrollments further highlights how the need to address this barrier to care is becoming more urgent.
As long as MA plans are allowed to use step therapy, patients treated under these private for-profit MA plans are not receiving the same health care that those in fee-for-service experience. Oversight action must be taken now to prevent a growing divide in the care available to MA enrollees versus traditional Part B enrollees. With that in mind, we urge the administration to protect patients’ access to care and expeditiously reinstate the prohibition on MA plans implementing step therapy.
Medical Records Requests
Another ongoing concern the Academy has with MA plans is how they are currently using their authority to request medical records and the burden that places on providers.
We have heard from ophthalmologists nationwide that plans are increasingly pushing for high volumes of chart audits and demanding incredibly tight turnaround times to provide the proper documentation. Requests with rapid required response windows may also be misrepresented as a part of Medicare Risk Adjustment Data Validation (RADV) instead of an internal organizational action. In combination, the volume and short timeline for medical records requests create a major demand on the already stretched work hours that office staff have available.
The burden of medical records requests is worse for smaller practices and those working with underserved communities that are still rebounding from the ongoing PHE. A significant and ongoing part of this recovery process is addressing shortages in key office staffing positions to meet these demands.
As the Medicare Payment Advisory Commission highlighted in their June 2019 report to Congress on Medicare and the Health Care Delivery System, the riskbased model for calculating Medicare’s payment rate to MA plans encourages “more thorough diagnostic coding in MA (greater “coding intensity”)” and “generates greater payment for MA plans than FFS Medicare would have spent for the same beneficiary.”8 It seems counterintuitive for MA plans using these kinds of requests to look for ways to increase their reimbursement while taking time away from patient care, which could worsen any underlying health equity issues affecting the MA beneficiary community.
The Academy believes scrutiny of MA plan medical records requests is critical to relieve administrative burden on physician practices, but also to ensure that CMS is paying MA plans accurately. CMS has the authority to step in and standardize the process for all medical records requests (e.g., requiring clear identification for the nature of the request and establishing consistent and reasonable deadlines).
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Considering current health equity issues, the expected long-term growth in Medicare Advantage enrollment, the shortfalls in patient care created by utilization management techniques like step therapy and prior authorization, and the abuse of the medical records request process failing to act now paints a dire future for MA beneficiaries’ ability to access the care they need. Given the access barriers these plans are creating and the robust profits enjoyed by the plan administrators, a proposed 8% increase in MA payments appears incongruous. The Academy hopes that our suggestions are considered as ways to prevent these issues from creating greater problems for patients and providers. We urge CMS to take a closer look at how prior authorization, step therapy, and medical records requests are being used by MA plans. CMS must consider how these issues are impacting patients and providers, and how the agency can exercise its authority to ensure that patients who rely on these plans are not receiving inferior care compared to those on traditional Fee for Service plans.
We look forward to ongoing collaboration with CMS to ensure Medicare Advantage beneficiaries have timely and burden-free access to sight-saving care and therapies.
Sincerely,
Michael X. Repka, MD, MBA, AAO Medical Director for Governmental Affairs
David B. Glasser, MD, AAO Secretary for Federal Affairs