Hospitals, physicians, and health insurance providers urge the Centers for Medicare & Medicaid Services (CMS) not to implement costly, conflicting prior authorization standards.
Leading health care associations have joined forces to push CMS to reconsider its proposed prior authorization standards.
In what AHIP described as a “remarkable demonstration of unity,” the American Medical Association (AMA), the American Hospital Association (AHA), and the Blue Cross Blue Shield Association (BCBSA) have joined the trade association of health insurance companies in calling for CMS to resolve the differences between two proposed rules published in December that would establish two different sets of standards and corresponding workflows to complete the prior authorization process.
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While the associations support prior authorization reform to ensure timely access to care, they say that the “inclusion of prior authorization standards in the Administrative Simplification proposed rule would conflict with the standards proposed in the Interoperability and Prior Authorization rule, which would ‘set the stage for multiple [prior authorization] electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate.’”
CMS aimed to make the prior authorization process more efficient and transparent when it published the Administrative Simplification proposed rule. If finalized as proposed, the agency 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. Payers would have 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.
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But the associations say the Interoperability and Prior Authorization rule, which was released a week prior to the publication of the Administrative Simplification proposed rule, creates another set of standards. Moving forward with two sets of standards would run counter to the goals of administrative simplification, cause confusion, slow implementation, and unnecessarily increase costs, the letter said.