GAO calls on CMS to continue prior authorization experiments – Modern Healthcare

If there is one thing physicians and patients dislike its pre-authorization. The perception is that any third-party getting involved delays care, may deny payment for care and of course, there is the paperwork and physician’s time involved. Nobody should come between the patient and their doctor, right?

There are a couple of things to consider. Somebody else is paying the bill (and it’s not the insurance company or the government – it’s other insured people and US taxpayers) and a second set of eyes can lead to better care at times especially considering that a considerable amount of health care provided is considered unnecessary.

If you are concerned about the cost of health care, you need to be open to different ways of attacking it. And remember, pre-authorization of one form or another is part of all single-payer systems.

The CMS hasn’t moved to continue prior authorization experiments even though they could save Medicare billions of dollars, according to the U.S. Government Accountability Office.

Under the experiments, the CMS only pays for some items and services after providers and medical product suppliers have shown they complied with coverage and payment rules. The CMS uses prior authorization in Medicare for non-emergency ambulance rides, hyperbaric oxygen therapy, home health services and power wheelchairs.

The CMS may have saved as much as $1.9 billion thanks to prior authorization since it started the experiments in 2012.

But most of the experiments have ended or will end soon, and the CMS hasn’t announced plans to continue the vast majority of those efforts, the GAO said in a report released Monday. One exception involves power wheelchairs, which fall under a permanent prior authorization program.

“By not taking steps, based on results from the evaluations, to continue prior authorization, CMS risks missed opportunities for achieving its stated goals of reducing costs and realizing program savings by reducing unnecessary utilization and improper payments,” GAO said.

Source: GAO calls on CMS to continue prior authorization experiments – Modern Healthcare

One comment

  1. Twenty-five years ago I ruptured a spinal disk. I had all the symptoms. I went to three doctors within two days and had an MRI. Before my insurance company would approve surgery, they demanded I personally speak to their representative while I was at the third doctor’s office so as to confirm what the doctor had just told them. To my knowledge, the insurance company has dis continued this kind of forced interrogation. Review, yes. Star chamber, no.


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