House Democrats are urging more transparency regarding what they term the new demonstrations from the Department of Health and Human Services (HHS), particularly concerning the introduction of pre-authorization requirements for Medicare.
A collective of 17 Democrats, led by Susan Delbene (D-Wash.) and Ami Bera (D-Calif.), are questioning HHS’s motives behind the proposed pre-authorization for traditional Medicare. This comes despite the Trump administration’s previous assertions aimed at reducing practices typical of Medicare Advantage (MA) plans.
Typically, traditional Medicare does not necessitate prior approval. However, it has been known to employ controversial practices focused on profit, which have spurred the growth of private MA plans.
“The Trump administration openly acknowledged the harm of prior statements. Yet, just a week later, CMS rolled out new proposals to ramp up pre-authorization for a type of health insurance that seldom used these tactics before, effectively replacing medical expertise with algorithms aimed at maximizing denials,” one lawmaker noted, referencing Medicaid’s St. Mecker.
There are also concerns surrounding a new pilot program from CMS that aims to assess models targeting “unnecessary and inappropriate services in original Medicare.”
This initiative entails CMS collaborating with private firms, including some Medicare Advantage Plans, to enforce prior permission for clinicians’ care requests.
Under this model, specific outpatient procedures identified by the agency as susceptible to fraud, waste, or inappropriate utilization will require prior authorization.
Participants will receive incentives based on the “effectiveness of technological solutions” in minimizing expenditures on unnecessary or uncovered services. Lawmakers fear this may foster damaging incentives, rewarding entities that deny the most care.
“Past experiences with prior approval have seen abuse over time, negatively impacting patients and healthcare providers,” the lawmakers expressed.
Analysis of 2023 data from HHS revealed that nearly 81% of rejections were either partially or fully overturned after appeals, as noted by KFF.
“Implementing prior authorization in Medicare Advantage will effectively limit beneficiaries’ access to care, add to the already heavy workload of healthcare professionals, and incentivize profit over patient care,” the letter stated.
The letter requested clarification from CMS regarding the pilot’s scope, implementation strategies, and protections for beneficiaries.
Simultaneously, the Trump administration is advocating for voluntary commitments from the health insurance industry to streamline the pre-authorization process for MA plans, suggesting an acknowledgment of the issues with prior approval.
“There’s real tension on the streets over these matters,” Oz commented at an event highlighting the industry’s pledge.
