Premier and 118 Member Organizations Call on CMS to Use Policy Levers in Medicare Advantage to Protect Patients’ Continuity of Care

Premier and 118 of our member organizations, ranging from large health systems to independent physician offices, sent a letter to the Centers for Medicare & Medicaid Services (CMS) highlighting the results of a national survey of hospitals, health systems and post-acute care providers that reveal the scope of payment delays and denials by private payers. Survey respondents reported serious concerns with payment delays and denials, which adversely impact patients’ timely access to medically-necessary care and impose unnecessary administrative and financial burdens on providers.

The organizations provide recommendations informed by an analysis of the survey on policy changes to advance the needs of patients enrolled in the Medicare Advantage program and the providers who care for them. Specifically, the organizations urge CMS to:

• Collect data on payment denials and delays by MA plans;
• Return to its past policy of weighting patient experience and access measures more heavily in the MA Star Ratings methodology, empowering beneficiaries to hold their health plans financially accountable;
• Take enforcement action against MA plans that fail to abide by the coverage rules of Medicare;
• Work expeditiously to enforce its recent regulatory changes to streamline prior authorization requirements in the MA program; and
• Require coverage determination reviews to be conducted by physicians of the same specialty for the service being reviewed – not a cost-containment algorithm.

The letter also calls on policymakers to stipulate that claims approved under an electronic prior authorization may not be artificially delayed or denied and for Congress to ensure CMS has the statutory authority needed to enforce its regulations, including by holding oversight hearings to combat bad actors in this space.

Premier partnered with our member hospitals and health systems in conducting the national survey to collect data on providers’ experiences with reimbursement delays and denials. More than 500 hospitals across 36 states, accounting for over 52,000 acute care beds, submitted responses.

See the full survey results here.