Last week, the Government Accountability Office (GAO) published a report determining that there is a nontrivial risk that prior authorization requirements, together with internal coverage criteria, may undermine the Medicare Advantage population's access to necessary health care services. GAO drafted this report pursuant to a mandate in the Consolidated Appropriations Act of 2023 that requires GAO to review the use of prior authorization requirements in the traditional-Medicare and Medicare Advantage programs. Despite these concerns, HHS was not particularly receptive to GAO’s recommendation that CMS “target behavioral health services in its program audit reviews of prior authorization denials and planned reviews of internal coverage criteria.”
Medicare Coverage of Behavioral Health Services
Though Medicare does not cover all levels of behavioral health care, such as some types of residential care, Medicare does broadly cover both inpatient and outpatient behavioral health services when the services “are reasonable and necessary for diagnosis or treatment of a behavioral health condition.” GAO emphasized that failing to treat behavioral health conditions can lead to consequences, such as “worsening health, frequent emergency department visits, hospitalizations, or premature death.” However, despite these severe consequences of under-treating behavioral health conditions, HHS estimates that approximately one-in-five U.S. adults aged 50 and older had a behavioral health condition, but that only “3 percent of MA enrollees received treatment from a behavioral health provider in 2023.” GAO speculates that this is the product of “barriers to accessing behavioral health services” and that the prior authorization process may be one of these barriers.
Prior Authorization Requirements
Medicare Advantage organizations sometimes require providers to receive “prior authorization” before providing certain services. This typically involves providers needing to “submit documentation, such as a diagnosis or description of current symptoms, to the MA organization[.]” Sometimes, this would involve Medicare Advantage organizations imposing their own “internal coverage criteria to make decisions.” Even though “CMS does not currently require prior authorization for any behavioral health services in traditional Medicare[,]” CMS does permit Medicare Advantage organizations to require prior authorization before treating patients and even allows these organizations to create their own internal criteria, so long as “the criteria ... not be more restrictive than Medicare coverage criteria.”
Per GAO, CMS posited that prior authorization helps to minimize unnecessary services, and GAO agreed, finding in 2018 “that expenditures for services subject to prior authorization were lowered by $1.1 to $1.9 billion compared with what would have been expected had the programs not been implemented, resulting in savings for the Medicare program.” However, after analyzing studies covering the issue, GAO is concerned prior authorization requirements may hinder beneficiaries from accessing care. GAO expressed concern that this process is often imperfect at making sure the entire population is treated, as HHS OIG found in an April 2022 report that “13 percent of care requests denied by [Medicare Advantage] organizations met Medicare coverage criteria.”
Also, while GAO found that prior authorization requirements may save money for Medicare, GAO also found that these requirements create new, substantial burdens for providers. A 2023 American Medical Association survey found that 35% of physicians “have staff who work exclusively on prior authorization” and that 95% of physicians reported that needing to work on prior authorizations “somewhat or significantly increase[d] burnout.”
GAO Recommendations for Improving CMS Oversight
GAO expressed concern that until CMS directs its oversight efforts on behavioral health services, “the agency lacks reasonable assurance that the use of internal coverage criteria does not compromise access to behavioral healthcare” for the covered population. Therefore, GAO made the sole recommendation that CMS “should target behavioral health services in its program audit reviews of prior authorization denials and planned reviews of internal coverage criteria.” HHS was unconvinced, pointing out (as described above) that “behavioral health services comprise a small percentage of [Medicare Advantage] services” as only “3 percent of MA beneficiaries received behavioral health services in 2023.”
Despite GAO’s concerns, HHS indicated that its reviews are focused on “the services that were most likely to be denied and negatively impact access for large numbers of beneficiaries,” meaning that the population treated for mental health services under Medicare was simply too small to justify the additional review and was a lower priority item. Some providers of behavioral health care services are concerned that this may be a sign of a negative cycle, whereby behavioral health services are rarer and less accessible because of insufficient oversight, and the oversight does not occur because of how rare the services are.
The full GAO report is available here, and the accompanying press release is available here.
