HHS Report Underscores Need for Prior Authorization Reform

From ACG Legislative and Public Policy Council Chair, Louis J. Wilson, MD, FACG

On Thursday, the HHS Office of Inspector General (OIG) released a report entitled, "Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care." This report helps highlight the need for Congress to reform prior authorization in the Medicare Advantage Program by passing the Improving Seniors’ Timely Access to Care Act (S. 3018; H.R. 3173).

The report’s findings are also consistent with the results from a recent ACG membership survey on prior authorization, concluding prior authorization is detrimental to patient care and overwhelming GI practices with wasteful and unnecessary burdens.

Among the highlights from the report: Medicare Advantage Organizations (MAOs) delayed or denied beneficiaries' access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage and billing rules. According to the OIG, these "denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers."

Medicare enrollment and spending continues to grow: According to a recent Kaiser Family Foundation (KFF) report on Medicare spending, Medicare benefit payments in 2020 totaled $769 billion, up from just under $200 billion in 2000. Spending is projected to increase to nearly $1.5 trillion in 2031, due to growth in the Medicare population and increases in health care costs. MAOs accounted for nearly half of all Medicare spending in 2021, up from just over a quarter in 2011. The share is expected to keep growing. Payments to MAOs nearly tripled from $124 billion to $370 billion over that timeframe. The number is expected to rise to $801 billion by 2030.

The number of Medicare beneficiaries is projected to grow from around 65 million people in 2020 to nearly 93 million people in 2060. The aging population is one factor contributing to higher Medicare spending, since spending per person is higher among older beneficiaries.

What does this report mean for ACG members? The HHS OIG recommends that Medicare revise and reform prior authorization rules for MAOs. Unfortunately, this will take time. So while there is no immediate change for ACG members and patients, the report highlights the need for Congress to immediately pass the Improving Seniors’ Timely Access to Care Act.

ACG advocated for this bill and other important issues impacting our patients and practices during the 2022 ACG Advocacy Day on April 7th. Thank you ACG members for being the voice of clinical GI on Capitol Hill!

Biden Administration to Appeal Texas Court's Surprise Billing Ruling

Other Notable Highlights for ACG Members:

Surprise Billing: The Biden administration recently filed an appeal to the February 2022 ruling in favor of the Texas Medical Association’s challenge to the federal No Surprises Act. The No Surprises Act became effective on January 1, 2022, but the rules related to the independent dispute resolution (IDR) process have been at issue after the federal government released rules that many organizations (including ACG) believe are inconsistent with the legislation. The U.S. House Ways & Means Committee Democratic and Republican leadership supported the February ruling. Click here for the press release from U.S. Representative Brad Wenstrup, D.P.M. (R-OH), which includes a quote from ACG President Samir Shah, MD, FACG.

Quality Reporting: The Centers for Medicare & Medicaid Services (CMS) announced that due to COVID-19, CMS will automatically be reweighting the MIPS Cost Performance Category from 20% to 0% for the 2021 performance period. The 20% cost performance category weight will be redistributed to other performance categories for both individual and group reporting mechanisms. ACG members do not need to take any action as a result of this decision because the cost performance category relies on CMS administrative claims data.

FDA Continues to Release Draft Guidance on Developing Drugs for Conditions in GI

From ACG FDA Related Matters Committee Chair, Eric D. Shah, MD, MBA, FACG

The U.S. Food and Drug Administration (FDA) continues to release draft guidance on developing new drugs for GI diseases. The FDA this week published draft guidances for developing drugs on Crohn’s disease and ulcerative colitis.

The Crohn’s draft guidance for adults and ulcerative colitis draft guidance both address FDA’s current thinking about necessary attributes of clinical trials for developing drugs for the treatments, including recommendations for trial population, trial design, and efficacy and safety considerations.

The FDA also recently announced draft guidance for industry entitled "Celiac Disease: Developing Drugs for Adjunctive Treatment to a Gluten-Free Diet."

ACG continues to work closely with the FDA on these draft guidance and other important treatments impacting our patients.

ACG Project Management Committee Initiative: Reimbursement Guidance

From ACG Practice Management Committee Chair, Stephen T. Amann, MD, FACG

The ACG Practice Management Committee continues to roll out initiatives for ACG colleagues and GI practices.

Do you have a Coding question? ACG’s new member-only benefit—Billing and Coding Forum, gives you access to our expert coding consultant Arlene Marrow, CPC, CMM, CMSCS. Brought to you by the ACG Practice Management Committee, this addition to the Toolbox offers professional coding and billing assistance for ACG members.