Industry Pushes CMS on Medicare Advantage Accountability Proposals

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ARTICLE SUMMARY:

The Medicare agency has proposed mandating more transparency and tighter controls on Medicare Advantage coverage and prior authorization policies, which are administered by private payors. Medtech groups say it’s a great first step but more is needed.

Enrollment in Medicare Advantage is growing at a rapid pace and is expected to overtake traditional Medicare sometime in the next few years. That’s a prospect that worries some in the device industry. The reason? MA plans, run by private insurance companies, feature coverage and payment procedures that are decidedly less transparent compared with standard fee-for-service Medicare. In addition, prior authorization requirements, which are rare in traditional Medicare, are a standard element of MA plans and too often delay or block appropriate care, argue medtech groups, as well as physician organizations. (See “Docs of the Month: Prior Authorization Under the Spotlight,” Market Pathways, May 11, 2022.)

Companies have recently been pressing CMS to bring the MA policymaking environment closer to the status quo of traditional Medicare, and the agency took steps in that direction late last year. CMS published a proposed rule in December that would require more transparency and tighter controls around MA coverage procedures and policies, and more restrictions on the use of prior authorization. Industry groups are praising the proposals, but say there is a lot more CMS should do to enforce the newly proposed requirements and to modernize MA decision-making.

CMS’ proposed rule “is a really important first step to crack open the black box that defines how private plans and MA plans make their coverage policies.”

Dan Waldmann, MDMA
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