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FAH Statement | Managed Care | FAH Policy Blog Team

FAH Quality Measure Recommended to CMS for Bringing Transparency and Accountability to MA Plan Denials  

A quality measure developed by FAH aimed at providing increased transparency and accountability in the prior authorization process used by Medicare Advantage plans was overwhelmingly approved by an independent, outside expert panel. 

The announcement was included in the Pre-Rulemaking Measure Review (PRMR) results released today by the Partnership for Quality Measurement. The Level 1 Upheld Denial Rate Measure developed by FAH will make transparent the extent to which MA plans’ denials of care or services are overturned on appeal, providing additional insights to seniors and regulators on whether or not plans are abusing the prior authorization process to arbitrarily deny or delay care. The recommendations will be sent to CMS after a public comment period for inclusion in the Medicare Part C and D Star Ratings program. 

FAH President and CEO Chip Kahn said:  

“Medicare Advantage plan members need to know the extent to which plans are denying or delaying care due to prior authorization abuse. FAH developed this important performance measure to shed light on Medicare Advantage plans’ practices that are baselessly denying or delaying care seniors need. We hope CMS will hold managed care companies accountable and increase transparency by including this measure in the next round of rulemaking.” 

Additional information on FAH’s Level 1 Upheld Denial Rate Measure: 

  • This measure will enhance CMS’ oversight of MA plans, help expose patterns of inappropriate care denials by insurance companies and hold health plans accountable. As a result, the measure will also provide beneficiaries with needed insights to inform their decision-making about plan membership. 
  • Specifically, the FAH measure will reveal the percent of Level 1 appeals where a plan’s determination was “upheld” by the plan out of all the reconsiderations made by the plan (upheld, overturned, and partially overturned determinations).  
  • The measure was recommended with 86.67% of the Clinician Recommendation Group members voting in favor. The committee noted the measure may “(1) reduce burden and improve transparency for patients and beneficiaries; (2) alleviate undue anxiety and delays; and (3) complement the existing Level 2 measure that is currently in the Star Ratings program. Together, the measures could reduce frustration of obtaining unnecessary prior authorizations with Medicare Advantage. The committee reached consensus on this measure and voted to Recommend the measure for inclusion in the Part C and D Star Ratings program.” 
  • For more on the Pre-Rulemaking Measure Review process, visit the Partnership for Quality Measurement at https://p4qm.org/PRMR.