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  • Writer's pictureTom Cianflone

Medicare Advantage Prior Authorization in the News

Updated: Jan 17

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If you're one of my clients, we have had the discussion about Medicare Advantage plans, that they are managed care plans, and that the carrier will have a say in whether or not a course of treatment recommended by your medical provider is available to you. Prior authorization is one means by which insurance carriers "manage" your care. Prior authorization in Medicare Advantage plans has been getting a lot of attention at the Federal level lately, in congress and such, but you'd only know about it if you watched C-SPAN (which, believe it or not, I do occasionally to keep up with Medicare changes). That's why I was pleased to see recently that the subject of Medicare Advantage prior authorization was picked up by mainstream media. Not a new story, but at least it's getting more exposure. Check it out here: NBC News clip on YouTube

Also, a new CMS rule goes into effect in 2024 that at least helps a little bit in the area of prior authorization. It used to be that if a Medicare Advantage plan member was not happy with the their care and decided to change plans in the middle of a course of treatment in the hopes of improving their care, they would be faced with an entirely new round of prior authorization hurdles by the new plan for the same course of treatment that had already been approved by their current plan. This new CMS rule changes that, plus a few other things. Read a synopsis of the new CMS rule here: New CMS Prior Authorization Rule Takes Effect

The new rule doesn't go far enough in many respects, but it's a good start. The winds may be blowing in the right direction to improve Medicare Advantage over time. We'll see.

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