2020 CMS prior authorization for hospital outpatient departments: Associated surgical volume impact.

[BACKGROUND] Prior authorization is common for privately administered Medicare Advantage plans but is rarely used for surgical care when considering publicly administered plans. A 2020 Centers for Medicare and Medicaid services (CMS) policy, CMS-1717-FC, requires prior authorization for Medicare Fee-for-Service beneficiaries undergoing select procedures (blepharoplasty, abdominoplasty, botulinum toxin injection, rhinoplasty, and vein ablation) in hospital outpatient departments. The impact of this policy on surgical volume at hospital outpatient departments and shifts in care to ambulatory surgery centers is unknown.

[METHODS] This study used a segmented interrupted time series and pre-post logistic regression model. This study was a retrospective cohort study using data from the Healthcare Cost and Utilization Project state ambulatory surgery database and state inpatient database.

[RESULTS] From 2016 through 2021, a total of 272,879 patients underwent the affected procedures. Pre-CMS-1717-FC, a trend of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-10.82, 95% confidence interval: -18.32 to -3.33, P = .01). In the post-implementation period, no change in the rate of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-3.45, 95% confidence interval: -36.15 to 29.25, P = .83). In the pre-policy period, Medicare Fee-for-Service beneficiaries were 46% less likely to use freestanding ambulatory surgery centers but 27% less likely to use hospital-owned ambulatory surgery centers.

[CONCLUSION] CMS-1717-FC was not associated with significant changes in hospital outpatient department volume beyond baseline trends. Policy aiming to right-size prior authorization for these procedures and considering site-of-service will balance the need to ensure medical necessity while constraining costs.