Medical associations urge CMS to pause prior authorization requirements

The American Medical Association (AMA) and dozens of specialty physician groups sent a letter to CMS on April 7 urging the agency to delay the implementation of new prior authorization requirements slated to go into effect this summer for certain outpatient services.

In the 2021 OPPS final rule, CMS finalized a proposal to expand prior authorization to two new service categories—cervical fusion with disc removal and implanted spinal neurostimulators—effective July 1, 2021.

In their letter to CMS, the AMA, Healthcare Financial Management Association, American College of Surgeons, and other medical groups describe ongoing concerns that the new prior authorization requirements would limit beneficiary access to medically necessary procedures. “We also worry that future expansions of prior authorization will unnecessarily delay access to care for even more beneficiaries and add administrative and cost burden for providers unless appropriate and transparent regulations are established,” the groups write.

They urge CMS to suspend prior authorization requirements for the two new services categories past July 1 and to withhold action on any further expansion of prior authorization requirements until the agency has:

• Conducted an analysis of the impact of prior authorization for the five procedures implemented in July 2020, including the extent to which Medicare contractors have been able to meet processing timeframes and the burden imposed upon providers and beneficiaries.
• Established specific criteria through a transparent process to guide its decision-making related to the use of prior authorization.