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Denials and Appeals

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Interoperability and Prior Authorization Proposed Rule

March 13, 2023

The Medicare Rights Center (Medicare Rights) appreciates this opportunity to comment on the Advancing Interoperability and Improving Prior Authorization Processes proposed rule.

Prior authorization is creating an ever-increasing burden on patients. We support many of the Centers for Medicare & Medicaid Services (CMS) provisions in this proposed rule that would reduce this burden by improving processes, timelines, access to information, and communication.

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Medicare Part D Appeals Problems and Options to Correct Them

March 1, 2023

The Medicare Part D appeals process is an essential safety valve, allowing access to needed prescription medications—such as those that are not on the plan’s formulary, or are subject to high cost sharing, when formulary or lower cost alternatives are not appropriate. However, Part D enrollees often struggle to successfully navigate this overly complex, multi-step, process, and it can also prove burdensome for pharmacists, plans, and prescribing physicians. This can result in delayed access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs for the patient and the Medicare program.

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Statement for the Record “Negotiating a Better Deal: Legislation to Lower the Cost of Prescription Drugs”

May 4, 2021

Immediate action is needed to transform the nation’s drug pricing system in ways that will lower prices, strengthen Medicare, and promote the well-being of those who rely on its coverage. H.R. 3 would significantly advance these goals, in part by authorizing Medicare to negotiate prices for certain drugs; imposing inflationary rebates; and restructuring Part D to cap beneficiary out-of-pocket costs at $2,000 per year, reduce the federal government’s liability, and better align pricing incentives.

Read More »

Interoperability and Prior Authorization Proposed Rule

March 13, 2023

The Medicare Rights Center (Medicare Rights) appreciates this opportunity to comment on the Advancing Interoperability and Improving Prior Authorization Processes proposed rule.

Prior authorization is creating an ever-increasing burden on patients. We support many of the Centers for Medicare & Medicaid Services (CMS) provisions in this proposed rule that would reduce this burden by improving processes, timelines, access to information, and communication.

Medicare Part D Appeals Problems and Options to Correct Them

March 1, 2023

The Medicare Part D appeals process is an essential safety valve, allowing access to needed prescription medications—such as those that are not on the plan’s formulary, or are subject to high cost sharing, when formulary or lower cost alternatives are not appropriate. However, Part D enrollees often struggle to successfully navigate this overly complex, multi-step, process, and it can also prove burdensome for pharmacists, plans, and prescribing physicians. This can result in delayed access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs for the patient and the Medicare program.

Statement for the Record “Negotiating a Better Deal: Legislation to Lower the Cost of Prescription Drugs”

May 4, 2021

Immediate action is needed to transform the nation’s drug pricing system in ways that will lower prices, strengthen Medicare, and promote the well-being of those who rely on its coverage. H.R. 3 would significantly advance these goals, in part by authorizing Medicare to negotiate prices for certain drugs; imposing inflationary rebates; and restructuring Part D to cap beneficiary out-of-pocket costs at $2,000 per year, reduce the federal government’s liability, and better align pricing incentives.