GAO Calls on CMS to Continue Prior Authorization Experiments

The U.S. Government Accountability Office (GAO) says the Centers for Medicare and Medicaid Services (CMS) has not authorized the continuation of prior authorization experiments despite the fact that they could save Medicare billions of dollars, reports Modern Healthcare . The experiments stipulate that CMS only covers some items and services after providers and medical product suppliers have shown they complied with coverage and payment rules. The agency uses prior authorization in Medicare for non-emergency ambulance rides, hyperbaric oxygen therapy, home health services, and power wheelchairs. GAO estimates that CMS may have saved up to $1.9 billion due to prior authorization since it started the experiments in 2012. However, most of the experiments have concluded or soon will, and CMS has not announced plans to continue most of these efforts, with the exception of those involving power wheelchairs. "By not taking steps, based on results from the evaluations, to continue prior authorization, CMS risks missed opportunities for achieving its stated goals of reducing costs and realizing program savings by reducing unnecessary utilization and improper payments," GAO warns. The office determined providers and suppliers have had problems with prior authorization, noting it can take months to secure required documentation from referring doctors and others before submitting a prior authorization request, while clinicians lack financial incentives to furnish that information. CMS officials say the agency was assessing the prior authorization programs and would consider GAO's findings and recommendations. CMS has hinted it is considering new experiments for items such as hospital beds and oxygen concentrators, given their high usage or improper payment rates.