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CMS Chief: Prior Authorization Needed to Fight “Fraud and Abuse”

Posted on Friday, October 19, 2018 6:59 PM

CMS Administrator Seema Verma believes that the government needs more legal authority over Medicare prior authorizations.

According to a report from Inside Health Policy, Barbara McAneny, President of the American Medical Association, told reporters that prior authorization is a major administrative burden and disrupts access to care.

“The average physician is either spending or paying for 14 hours a week of staff time to spend time talking to the people that the insurance company pays to talk to us about care,” McAneny told Inside Health Policy. “One of my health plans said to me, ‘You know we never turn you down,’ and I said ‘Now why are you still torturing us with all this prior authorization process if you’re never going to turn us down?’ This is one of the areas of documentation that we absolutely have to fix.”

Despite the pushback from providers, CMS seems determined on implementing prior authorization. 

“The Medicare program has extremely low administrative costs, but this isn’t exactly something to brag about,” Administrator Verma said on Tuesday. “The reality is we aren’t focusing enough on critical program oversight functions like medical reviews of claims.”

“We review less than two tenths of a percent of the over one billion claims that Medicare receives a year.  Given the scope and size of the Medicare program, that is ridiculously low.  We also lack adequate legal authority to do the types of prior authorization reviews that have become routine in the private sector, leading to a high frequency of improper payments, and more fraud and abuse.”

Source: NAHC Report


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