Dear Administrator Oz: 

Congratulations on your confirmation as Administrator of the Centers for Medicare & Medicaid Services (CMS). Your clinical expertise strengthens the agency’s efforts to improve quality and patient safety. 

On behalf of Louisiana’s healthcare providers and the communities they serve, we applaud your comments in support of reducing potentially harmful patient-care delays and unnecessary administrative burdens for providers within the Medicare Advantage (MA) program. 

Our nation’s heightened healthcare workforce development challenges make it more important to reduce administrative burden on providers so they can focus their time on patient care. 

During the committee hearing, you called the broken MA care-approval process, known as prior authorization, “a pox on the system,” adding that “this is a place where it’s a matter of competency. This is not a Republican/Democrat issue.” You also recommended practical improvements to help expedite needed care, including reducing the frequency of prior authorization requirements. When used appropriately, prior authorization helps patients receive safe, timely, and affordable access to evidence-based care, but when used inappropriately, patients face delays that can jeopardize medical outcomes. As MA enrollment grows by offering lower costs and added benefits, we urge CMS to improve the popular program in three simple ways. 

1. Strengthen oversight and enforcement to stop inappropriate care denials. 

As you know, for nearly a decade, the Department of Health and Human Services Office of Inspector General (HHS-OIG) has reported that MA plans sometimes deny care that would be covered under traditional Medicare. While MA insurers overturn more than 80 percent of appealed care denials in favor of the patient, these denials result in potentially harmful care delays. Louisiana providers continue to report inappropriate delays for cancer and heart disease patients, as well as those who need intensive therapy to recover from stroke or amputation. 

To protect patients, CMS finalized a 2024 MA rule to clarify “clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in traditional Medicare.” In a statement, the agency said it “may issue compliance and enforcement actions, including civil monetary penalties to MA organizations who fail to comply with our regulations.” We look forward to the agency’s annual report on these activities.

CMS can better target these enforcement activities by requiring individual MA plans to report services they inappropriately deny. Federal lawmakers and a wide range of stakeholders have argued that MA insurers only report aggregate-level data, which is insufficient for enforcement of the 2024 MA final rule protecting beneficiaries’ access to part A and B benefits. Last year, the federal government paid MA plans more than $462 billion to cover more than 32 million people. Yet, a lack of meaningful data severely limits federal leaders’ ability to discourage improper care delays and denials. Kaiser Family Foundation (KFF) researchers found that “without plan-level data, by type of service, it will not be possible to determine whether plans are complying” with the 2024 MA rule.

 2. Inform seniors as they shop for plans. 

KFF also found that “substantial data gaps remain that limit the ability of Medicare beneficiaries to compare Medicare Advantage plans offered in their area.” Simplified comparisons of local MA plans’ behavior on this issue would help seniors who want timely access to care that CMS has already told insurers they must cover. Senate Finance Committee members found that “a lack of public data prevents seniors and people with disabilities from making informed decisions about which plan fits their needs.” When comparing other payers to MA plans, CMS recognized that Medicaid managed care plans already provide more specific plan-level data that “allow beneficiaries and states to compare plans.” Likewise, CMS could empower seniors to identify local MA plans with high levels of overturned denials through Medicare’s existing Star Ratings system. Last year, a group of national quality experts overwhelmingly supported this consensus recommendation to CMS.

3. Remove arbitrary barriers for providers who practice evidence-based medicine. 

We again applaud your commitment to improvements in this area and your reference to feedback you received from medical providers who simply want to provide the most timely and appropriate care for their patients. Providers remain frustrated by MA denials that contradict expert clinical guidelines and Medicare coverage rules. A study by Premier, Inc. found that the cost of navigating through insurers’ outdated care-approval processes exceeds $25 billion a year. CMS has scheduled a variety of updates designed to streamline MA prior authorization in 2026, including timeliness standards and internal verifications that MA insurers are meeting Medicare coverage guidelines. We urge CMS to consider other patient access improvements, including a 24-hour turn around for urgent care requests. 

Your agency can save lives and reduce costs by focusing on these three basic improvements to America’s growing MA program. We thank you for your service to patients and look forward to working with you on this important issue. 

Sincerely, 

Ralph L. Abraham, MD Surgeon General Louisiana Department of Health 

Paul A. Salles President & CEO Louisiana Hospital Association 

Karen C. Lyon, PhD, MBA, APRN-CNS, NEA CEO & Appointing Authority Louisiana State Board of Nursing 

Jeff Williams Executive Vice President and CEO Louisiana State Medical Society