On September 18, Applied Policy attended a briefing on prior authorization in Medicare Advantage (MA) hosted by Georgetown University’s Medicare Policy Initiative. The event featured industry leaders and policy experts, including Jeannie Fuglesten Biniek (Associated Director of Program on Medicare Policy, KFF), Neil Patil (Senior Research Fellow and Policy Director, Medicare Policy Initiative), and Rodrigo Cerda (Senior Vice President of Health Services and Chief Medical Office, Independence Blue Cross). The panel was moderated by Carrie Graham (Research Professor and the Executive Director, Medicare Policy Initiative).
Representative Judy Chu offered opening remarks, noting her upcoming legislation regulating the use of AI in prior authorization. The briefing was broken down into three sections, each led by a panelist. The first, presented by Fuglesten Biniek, provided background information and data on MA. He also highlighted some gaps in CMS requirements for reporting of Medicare Advantage prior authorization data, leading to an opaque approval process. More specifically, there is a lack of transparency around why PA requests are denied, the characteristics of enrollees who have PA requests denied, how PA requests, denials, and appeals vary across types of services, and what share of providers are exempt from PA requirements.
The second, presented by Patil reviewed recent relevant legislation around MA and described the upcoming WISeR model from CMMI, which will impact traditional Medicare. He provided a brief overview of 2023-2026 new CMS prior authorization regulations, including the CY 2024 MA-PD Final rule, the Interoperability & PA Rule, the CY 2025 MA-PD Final Rule, and the CY 2026 MA-PD Final Rule. He also discussed the Improving Seniors Timely Access to Care Act, a recently introduced act that would require MAOs to establish electronic prior authorization programs, would establish certain enrollee protections, and would provide CMS with the authority to establish time frames for real time decisions. He touched on the Reducing Medically Unnecessary Delays in Care Act, which removes “not meeting evidence-based standards” as a valid reason for denial and allows physicians to make the final decision for PA requests.
The final section was presented by Cerda and explained Independence Blue Cross’s pilot Utilization Management (UM) Simplification Program, a “health plan perspective on improving prior authorization.” Cerda detailed a payer’s perspective on prior authorization, noting it gets patients to the appropriate care, protects patients from duplicate services, and ensures care remains affordable. With medical experts leading reviews of prior authorization requests and using evidence-based guidelines, Cerda asserts the UM Simplification Program streamlines prior authorization into a useful lever. He noted the industry pledge payers including Independence Blue Cross have signed to improve the prior authorization process and ensure it does not limit access to care for beneficiaries.
Overall, the briefing focused on future directions for prior authorization and explored potential areas for innovation. The Medicare Policy Initiative is hosting a series of briefings and will continue bringing together experts in the field to discuss Medicare Advantage.
KEY TAKEAWAYS:
Background on MA:
- Most MA enrollees must receive prior authorization for services deemed “high cost.”
- MA insurers determined nearly 50 million prior authorization requests in 2023.
- In recent years, about 10% of requests have been denied.
- Insurers have different rates of prior authorization use.
- The MA prior authorization data reported to CMS have gaps.
Legislation on MA:
- Recent legislation impacting MA has aimed at reducing delays and improving access.
- Improving Seniors Timely Access to Care Act
- Reducing Medically Unnecessary Delays in Care Act
- Upcoming WISeR Model from CMMI in 2026
- CMS Prior Authorization Demonstration for Certain Ambulatory Surgical Center Services
- New CMS regulations will require MA organizations to follow Traditional Medicare laws and regulations as well as the regulations of NCDs and LCDs. MA organizations may establish internal coverage criteria under specific circumstances.
- New reporting metrics will begin in 2026 with electronic authorization programs beginning in 2027.
UM Simplification Program:
- Pilot program by Independence Blue Cross
- Collaboration with health systems and practices to simplify prior authorization
- Identifies high-performing clinicians
- Similar to a gold carding program, but providers are continuously evaluated
- Future directions for the program:
- Epic payer platform
- Potential for AI
- Moving UM upstream
Download a copy of this summary here.
