CMS proposes rule on prior authorization
The Centers for Medicare and Medicaid Services (CMS) has published a proposed rule aimed at streamlining the prior authorization process.
Prior authorization, which requires healthcare providers to get approval from insurance providers before giving certain treatments to patients, has been long-hailed as extremely burdensome to physicians and even causing delays in patient care. The proposed rule would modernize the healthcare system by requiring an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests and establish policies to make the prior authorization process more efficient and transparent.
According to CMS, the efficiencies in the changes would save physician practices and hospitals $15 billion over 10 years.
“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote healthcare data sharing to improve the care experience across providers, patients and caregivers––helping us to address avoidable delays in patient care and achieve better health outcomes for all.”
The rule also requires payers to implement standards for data exchange from one payer to another when a patient changes payers or has concurrent coverage. That requirement aims to ensure that complete patient records would be available throughout patient transitions between payers.
According to CMS, the changes in the proposed rule address the challenges providers face under prior authorization rules. The proposals include:
- Implementation of a Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard Application Programming Interface (API) to support electronic prior authorization
- Requirements for certain payers to include a specific reason when denying requests
- Publicly report certain prior authorization metrics
- Send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests––twice as fast as the existing Medicare Advantage response time limit
- Add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category
CMS would also expand the current patient access API to include prior authorization decisions; give providers access to patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and create longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.
Additionally, the proposed rule “includes five requests for information related to standards for social risk factor data, the electronic exchange of behavioral health information among behavioral health providers, improving the exchange of medical documentation between certain providers in the Medicare Fee-for-Service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interoperability can play in improving maternal health outcomes,” CMS stated.
The public and stakeholders can comment on the proposed rule until March 13, 2023.
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."