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Only Physicians With Relevant Expertise Should Handle Prior Authorization Disputes: Doctors Groups

𝗧𝗵𝗶𝗻𝗸𝙁𝘼𝙎𝙏. Here’s one that is so obvious that you have to wonder how it took this issue so long to come to the surface.  In its draft policy review for 2024, Centers for Medicare & Medicaid Services (CMS) is looking to clarify the extent to which physicians who are in positions that review “prior authorization” requests should have “relevant expertise” in the treatment area in which they are passing judgement.  The AMA and the AAFP have both weighed in on this issue, reporting what they see as unwarranted denials and delays in receiving prior authorizations due to reviewers’ lack of such expertise.  

And then there is the question as to what constitutes appropriate credentialing here.  The current draft would not require the reviewer to be of the same specialty or subspecialty as the physician making the request, instead providing Advantage programs with latitude in defining “relevant expertise.”  

Clearly this is a major issue. Now that it has finally surfaced, it needs to be dealt with appropriately and definitively.  You can read more about this at:


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