CMS Launches New Medicare Advantage Provider Complaint Form
Published Date:
Submit a Medicare Advantage provider complaint to CMS here.
NCODA firmly opposes step edits and other utilization management practices that delay or restrict access to evidence-based oncology care. These policies can interfere with clinical decision-making, delay treatment, and impose unnecessary burdens on patients and cancer care teams. Ensuring timely access to appropriate cancer therapies remains a top advocacy priority for NCODA.
The Centers for Medicare & Medicaid Services (CMS) has launched a Medicare Advantage Provider Complaint Form, giving healthcare providers a direct way to report concerns related to Medicare Advantage plan practices. NCODA strongly encourages oncologists and their cancer care teams to use this CMS tool to help address ongoing barriers to timely, high-quality oncology care.
CMS regulations allow Medicare Advantage plans to implement step therapy programs for Part B drugs only when specific requirements are met. NCODA believes many oncology-related step therapy practices fail to meet these standards and may negatively impact patient care.
Under CMS guidance, Medicare Advantage plans implementing step therapy programs must:
- Base clinical decisions on the strength of scientific evidence and accepted standards of medical practice.
- Consider peer-reviewed medical literature, pharmacoeconomic studies, outcomes research data, and other clinically appropriate evidence when making coverage decisions.
- Evaluate whether a step therapy requirement provides meaningful therapeutic advantages related to safety and efficacy.
- Ensure utilization management policies support clinically appropriate care and do not create unnecessary barriers to treatment.
- Maintain policies that protect patient access to medically necessary therapies and support individualized clinical decision-making.
NCODA is concerned that many oncology-related step therapy requirements do not adequately account for the complexity and urgency of cancer treatment decisions. Inappropriate step edits may:
- Delay access to evidence-based cancer therapies.
- Force patients to try therapies that may not be clinically appropriate.
- Disrupt physician-directed treatment plans.
- Increase the risk of disease progression or adverse outcomes.
- Create additional administrative burden for providers and cancer care teams.
When submitting a complaint to CMS, healthcare professionals are encouraged to describe situations where Medicare Advantage plan requirements:
- Delayed medically necessary oncology treatment.
- Overrode physician clinical judgment.
- Failed to consider current evidence-based standards of care.
- Required therapies that lacked therapeutic advantage for the patient.
- Created patient safety concerns or treatment disruptions.
- Resulted in repeated prior authorization delays or inappropriate denials.
The CMS provider complaint form allows providers to formally submit concerns related to Medicare Advantage plan behavior, including access issues, prior authorization delays, step therapy requirements, and denial patterns. All submissions are entered into a centralized CMS tracking system, enabling regulators to identify trends, assess compliance, and take action when plan practices negatively impact patient care.
Provider-reported data is essential to improving oversight and accountability. CMS relies on documented complaints to better understand how Medicare Advantage plan requirements affect real-world patient care, clinical outcomes, and provider burden.
Please take a few minutes to share your experiences. Your perspective is critical to helping CMS understand how Medicare Advantage plan practices affect oncology care delivery and patient outcomes.
Together, we can advocate for timely access to evidence-based cancer treatment, reduced administrative burden, and a healthcare system that better supports patients with cancer.
NCODA will continue sharing additional information and advocacy resources related to step therapy and broader utilization management practices impacting oncology care. Please visit NCODA’s Step Edits Hub for more information.
Submit a Medicare Advantage provider complaint to CMS here.