
Health Plans’ Gambit On Prior Authorization
Health plans preempt CMS action on prior authorization with reforms of their own For the past few years, the feeling was palpable at health plans. State and federal regulators and lawmakers were tightening the screws on health plan prior authorization (PA). And so to preempt further regulatory action on the issues, plans have agreed to make further reforms on their own. What changes are already in place? On the Medicare Advantage (MA) front, the Centers for Medicare and Medicaid Services (CMS) did a number of things on the PA front. For the past decade, the agency has honed its program audit protocols for both pharmacy and medical service requests and appeals. It spends a great deal of time on recent audits diving into the whole PA life cycle and digs deep on the application of medical necessity criteria for both pharmacy and medical services. It also finalized a significant interoperability