Tuesday, May 28, 2024

New York Times: Not Happy about Prior Auth Burdens in Medicare Advantage

Excessive and burdensome prior authorizations are a hotspot for the AMA, have gotten attention both in Medicare regulations and in Congress, and are increasingly discussed in trade journals for the lab industry, such as 360Dx this month (Adam Bonislawsky). See also Dark Daily.

Now the New York Times weighs in with a feature article about burdens of Medicare Advantage, in a detailed article appearing over the Memorial Day Weekend.   Find it here:


Written by Paula Span, the article got over 400 comments in the first couple days.

Here are some key points:

  • The case study is a woman on Medicare who, after a stroke, was in rehab and progressing well.  On a Wednesday, she and her husband were notified that her care was canceled by her Medicare Advantage plan, and they had to be "out the door" by Friday.
  • Only 11% of Medicare Advantage denials are appealed, yet of those, over 80% are overturned.
  • Medicare recently published new regulations and guidance documents about M.A. rules including for coverage and for prior auth.
  • Some of the new rules don't come into play until 2026.  But CMS promised the NYT that it would make efforts to enforce the updated (or clarified) policies.

See an article and case study at MedScape (registration required) here.