Payer, Provider Orgs React to Prior Authorization Proposed Rule

Payer and provider organizations are responding positively to the CMS proposed rule that would change the prior authorization process to better support electronic prior authorization.

“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 the CMS press release. “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.”

The proposed rule applies to Medicare Advantage organizations, Medicaid and CHIP managed care plans, Medicaid and Children’s Health Insurance Program (CHIP) agencies, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).

The proposed rule would require the implementation of Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard Application Programming Interface (API) and mandates that payers have to explain the specific reason behind a prior authorization denial. Expedited prior authorizations will have to occur within 72 hours and non-urgent prior authorizations will have to be turned around in seven calendar days.

A variety of organizations responded with positive feedback.

“Better Medicare Alliance thanks CMS for their leadership in modernizing the prior authorization process for beneficiaries,” Mary Beth Donahue, president and chief executive officer of the Better Medicare Alliance, said in a BMA press release.

“While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization’s essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community’s work streamlining this clinical tool to better serve its 30 million diverse enrollees. We additionally welcome the proposed rule’s data exchange provisions, which will further improve communication between health plans, providers, and beneficiaries.”

Donahue also pointed out that the rule addressed budgetary concerns tied to legislation that Better Medicare Alliance supported.

AHIP cited its Fast PATH initiative as evidence of the efficiency of electronic prior authorizations.

“AHIP’s Fast PATH demonstration showed that electronic processes for prior authorization are essential for ensuring that patients receive swift, evidence-based care that improves value and reduces administrative burdens for everyone,” Matt Eyles, president and chief executive officer at AHIP, shared in an AHIP press release.

“This proposed rule would require clinicians and hospitals to adopt electronic prior authorization to meet certain quality measures, ensuring that we are all incentivized to work together for a better patient and clinician experience that improves satisfaction, efficiency, and affordability for everyone.”

The payer organization urged policymakers in CMS and the legislative branch to collaborate in order to find a solution to improve personal health information sharing and protect personal health data.

The Medical Group Management Association (MGMA) which represents over 15,000 group medical practices was also supportive of the prior authorization rule, acknowledging the heavy burden that manual prior authorizations place on providers.

“MGMA is encouraged to see that CMS heeded our call to include Medicare Advantage plans in the scope of this proposed rule. An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals,” Anders Gilberg, senior vice president of government affairs for MGMA, said in a press release.

“The onerous methods of completing these requests, coupled with the increasing volume is unsustainable. An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care. This is a positive step forward for both medical groups and the patients they treat. We look forward to working with CMS to refine and finalize this rule.”