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We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: CMS clarified that disclosures are not publicly accessible if they require a password or cannot be easily accessed through a payer\u2019s website. AMA called for additional updates, like standardized reporting. CMS has updated its guidance on prior authorization metrics reporting, addressing the AMA\u2019s concerns about how health insurers were disclosing requirements and outcomes, according to the organization. The AMA said it notified CMS about issues with reporting metrics after it conducted a review examining how 15 Medicare Advantage contracts were abiding by the transparency requirements from CMS\u2019s 2024 Interoperability and Prior Authorization final rule.
CMS clarified that disclosures are not publicly accessible if they require a password or cannot be easily accessed through a payer\u2019s website. Image: Adobe Stock
The review showed that \u201con the surface, many plans appeared to comply with the rule while presenting disclosures in places and formats that made them difficult or impossible to find or use,\u201d the organization said. \u201cPlans posted hundreds of pages of billing codes without plain-language descriptions, buried required disclosures behind physician or member portals and deep within plan websites, reported mathematically impossible statistics and turnaround times without units, and omitted entire categories of care \u2014 including behavioral health and post-acute services \u2014 from public reporting.\u201d \u201cPatients should not need a portal password, a billing manual or medical training to find and understand a health plan\u2019s prior authorization practices,\u201d AMA President Willie Underwood III, MD, MSc, MPH, said in a press release. \u201cYet that is what we found when we examined how plans were implementing these transparency requirements. One plan posted an 832-page list of billing codes without a word of plain English. Others buried required information behind portals. Another published numbers that didn\u2019t add up \u2014 and acknowledged that its data should \u2018not be relied upon.\u2019 In other words, thank you for reading this. The information may or may not be true.\u201d Updates to guidance The guidance, AMA said, now clarifies that: health plans must publicly identify all medical items and services needing prior authorization, \u201caddressing the omission of entire categories of care from plan disclosures\u201d; all turnaround-time metrics need to include a time unit, and median times less than 1 day must be reported in hours rather than \u201c0 days\u201d; disclosures are not publicly accessible \u201cif they are available only through password-protected portals or cannot be reached through ordinary navigation from a payer\u2019s public-facing website\u201d; and procedure codes that do not have plain-language descriptions \u201cdo not satisfy\u201d disclosure requirements. \u2018The work is not finished\u2019 CMS \u201chas taken an important step toward making prior authorization information more transparent and usable,\u201d Underwood III said, \u201cbut the work is not finished.\u201d AMA urged CMS to continue improving its guidance on transparency by: making health plans provide direct links to their prior authorization requirements and performance metrics upon enrollment and requiring states to \u201cinclude the same links in Medicaid and CHIP plan-comparison and enrollment tools\u201d; defining prior authorization by how its process functions \u201cregardless of whether a payer calls it \u2018prior authorization,\u2019 \u2018precertification,\u2019 or \u2018advance notice,\u2019 or delegating the process to a third-party utilization management vendor\u201d; and standardizing prior authorization reporting by requiring standardized templates vs. simply recommending them. \u201cPatients and physicians need information that is accurate, accessible, understandable and comparable across health plans. You shouldn\u2019t have to be a rocket scientist to figure out what the insurance companies are doing,\u201d Underwood III said. \u201cThe AMA will continue working with CMS to make sure transparency requirements actually deliver transparency.\u201d Sources\/Disclosures Source:
Press Release
Reference:
Disclosures:
Healio could not determine relevant financial disclosures at the time of publication.
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