Trump administration tiptoes into testing prior authorization in traditional Medicare

[Yo_Mama_Been_Loggin]

Traditional Medicare plan holders have typically not had to wait for prior authorization before receiving medical treatment.

Until now.

The Centers for Medicare & Medicaid Services (CMS) recently announced a new program to test prior authorization requirements for certain services in six states starting Jan. 1.

The states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — will apply prior authorization evaluations to more than a dozen services.

CMS says the pilot program is intended to root out “fraud, waste, and abuse,” but as Medicare Advantage members know well, prior authorization can lead to frustrating delays in care.

https://finance.yahoo.com/news/trump-administration-tiptoes-into-testing-prior-authorization-in-traditional-medicare-143012089.html

[LoisB]

1. P.O.S.

[Silent Type]

2. This was actually proposed late in Biden's term, although the treatments weren't released at that time.

[Ms. Toad]

4. Pretty sure Biden was cracking down on Medicare Advantage's use of prior authorization -

Not adding requirements to Medicare.

[Silent Type]

5. That too. But original Medicare has used prior-authorization at times for services with high

probability of being questionable.

Biden’s Admin could have forced MA, ACA plans, and Medicaid private plans to improve denial hassles, audit denials, require stats, etc., but didn’t get into that until 2024, unfortunately.

[Ms. Toad]

6. Correct -

But I was addressing your claims that Biden was introducing prior authorization to Medicare. That is not accurate. Biden was working on decreasing Medicare Advantage's detrimental reliance prior authorization. Pretty much the opposite of your claim.

As to Medicare's prior authorizations - they are, largely, limited to treatments which have both non-medical and medical uses. Like blepharoplasty (eyelid lifts). It is both a medical treatment for limited vision by eyelids drooping into the line of vision and limiting it - as well as a cosmetic procedure for people who dislike the heavy-lidded appearance.

The procedures included in the article do not fall into that category. They are purely medical.

[Silent Type]

8. No. CMS also proposed prior authorization for original Medicare for procedures/treatments like skin substitutes, etc.

[Ms. Toad]

10. That is now, under Trump. n/t

[Ms. Toad]

3. Oh crap. Let's turn Medicare into Medicare Advantage.

One of the things on the list is a skin substitute. It was just before I was on Medicare, but I had to fight with an insurance company for a cadaver graft to cover my 5" diameter open wound for 3 weeks while pathology minutely examined the aggressive cancer they removed, to be sure they didn't need to do 2 autografts, in case they hadn't gotten it all. It actually didn't require prior authorization - it was a coding error, but it is something I am intimately familiar with.

Prior authorization would have required delaying surgery for an aggressive tumor which doubled in size in about 2 weeks.

The things which currently require prior authorization, by and large, are things which are both cosmetic and functional (For example, my spouse's vision was limited by her eyelids drooping into her line of vision - so the reason she had the surgery to remove part of her eyelids as medical. But my SIL wants to have it done for cosmetic reasons. That surgery requires prior authorization.) The things they are talking about now are not frequently abused procedures.

[catrose]

7. Prior authorization absolutely sucks

[lostnfound]

9. Trump death panels

GOP has been projecting for a long time.