The Centers for Medicare & Medicaid Services (CMS) on Tuesday issued a proposed rule that aims to streamline prior authorizations and improve patient and provider access to health information.
Prior authorization is an administrative process that providers use to request approval from payers before they deliver medical items or services. The process is meant to ensure that the items and services are medically necessary and covered by the payer but has become a major source of provider burnout and can become a health risk for patients if the process causes care to be delayed.
To make the prior authorization process more efficient and transparent, CMS would require plans to implement an electronic prior authorization process, shorten the time frames to respond to prior authorization requests, and establish policies to make the prior authorization more efficient and transparent. The 403-page rule also proposes to require payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage. The change aims to help ensure that complete patient records would be available throughout patient transitions between payers.
The rule applies to Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, Children’s Health Insurance (CHIP) agencies and CHIP managed care entities, issuers of qualified health plans on the Federally-facilitated exchanges, Merit-based Incentive Payment System (MIPS) eligible clinicians, and eligible hospitals and critical access hospitals in the Medicare Promoting Interoperability Program.
“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” said CMS Administrator Chiquita Brooks-LaSure in an announcement. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care 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.”
Here are five things to know about the proposed rule:
Supports electronic prior authorization: CMS would require implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. In addition, payers must include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited/urgent requests and seven calendar days for standard or non-urgent requests, which is twice as fast as the existing Medicare Advantage response time limit. However, CMS is also seeking comments on alternative time frames with shorter turnaround times, for example, 48 hours for expedited requests and five calendar days for standard requests. The proposed rule would also add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for MIPS eligible clinicians under the Promoting Interoperability performance category.
Improves access to health data: Proposed policies expand the current Patient Access API to include information about prior authorization decisions; allow providers to access their 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.
Could save billions: CMS estimates that the efficiencies introduced through these policies would save physician practices and hospitals over $15 billion over a 10-year period.
Seeks feedback on additional issues: CMS 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. The deadline to submit comments about the proposed rule is March 13, 2023.
Gives organizations three years to prepare for the changes: If finalized, the prior authorization policies would take effect January 1, 2026, with the initial set of metrics proposed to be reported by March 31, 2026. CMS said the implementation date would provide sufficient time for organizations to recruit and train staff, update, or build the APIs, and update operational procedures.