MA Prior Authorization Rule Comment Period Ends and Algorithmic Claims Denials

In December, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule that would require all health plans, including Medicare Advantage plans, to limit prior authorization deliberations to seven days. On Monday, the public comment for that rule closed.

Many providers believed that the rule doesn’t go far enough, arguing that seven days is too long for insurers to deliberate. Kaiser Health News reports that some states have taken steps to speed up the process themselves, with Oregon requiring responses to prior authorization requests within two days and Michigan requiring annual reports of prior authorization data.

More than 80% of physicians report that prior authorization requirements by health insurers lead to higher overall utilization of health care resources, which in turn leads to waste, according to a survey conducted by the American Medical Association (AMA). From AMA President Jack Resneck Jr., M.D.:

Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care and harm patients.

The Medical Group Management Association (MGMA) and the Workgroup for Electronic Data Interchange (WEDI) commented on the proposed rule to voice their support for including Medicare Advantage plans in the final rule. According to Healthcare Finance News, the organizations also suggested that the provisions should be implemented earlier than the proposed date of January 1, 2026.

But prior authorization is not the only point of concern for denials of needed care. This week STAT News published an investigation that found Medicare Advantage insurers are increasingly using unregulated predictive algorithms to choose when to deny care. From David Lipschutz, associate director of the Center for Medicare Advocacy:

While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow. There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.

Skilled Nursing News also noted that the reliance on algorithms is compromising post-acute care for nursing home residents. Analysis showed dozens of nursing home residents who were denied necessary care due to UnitedHealthcare’s adherence to recommendations proffered by NaviHealth software.