CMS Proposes Rule to Streamline Prior Authorization, Data Exchange

The Centers for Medicare & Medicaid Services (CMS) proposed a new rule aiming to boost patient data exchange and streamline prior authorization to alleviate clinician burden.

Additionally, the rule would allow providers to improve patient care and spend more time with their patients.

Prior authorization is a key utilization management strategy many healthcare payers use to ensure patients access the most clinically and cost-effective medication available to them. When a drug has prior authorization requirements, the provider must submit certain documents to a healthcare payer to receive permission before prescribing the drug.

Completing prior authorization can be demanding for providers and lead to delays in patient care access, with 46 percent of clinicians submitting authorization requests by fax and 60 percent made over the telephone. However, electronic prior authorization is becoming more prevalent in the medical field.

“Prior authorization is a necessary and important tools for payors to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing administrative costs for the whole system,” Seema Verma, administrator of CMS, said in a statement.

This proposed rule intends to build upon the CMS interoperability rule by increasing interoperability and patient access to data. Effective patient data exchange and improved interoperability can also help minimize the spread of the coronavirus. 

“This proposed rule ushers in a new era of quality and lower costs in health care as payors and providers will now have access to complete patient histories, reducing unnecessary care and allowing for more coordinated and seamless patient care,” Verma continued. “Each element of this proposed rule would play a key role in reducing onerous administrative burden on our frontline providers while improving patient access to health information.”

CMS said the proposed rule would force Medicaid, CHIP, and QHP programs to develop application programming interfaces (APIs) to back patient data exchange and prior authorization. Payers across the country would integrate the APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. The Office of the National Coordinator (ONC) for Health Information Technology proposed adopting this standard for the interoperability rule.

“Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients,” Verma said. “If just a quarter of providers took advantage of the new electronic solutions that this proposal would make available, the proposed rule would save between 1 and 5 billion dollars over the next ten years. With the pandemic placing even greater strain on our health care system, the policies in this rule are more vital than ever.”

If passed, this rule would require payers to integrate an FHIR-based API to streamline patient data exchange. Patients would have full access to their medical histories and bring this data from one payer to another. 

Payers, providers, and patients would gain more access to information, including past and pending prior authorization decisions, which would reduce administrative burden, cut costs for providers, and boost patient care.

“For patients, there will be no more wrangling with prior providers and locating ancient fax machines to take possession of one’s own data; for providers, there will be no more piecing together patient health histories based on incomplete, half-forgotten snippets of information pried out of the patients themselves; for payers, this is the first step towards building the important data sharing systems we need to move towards value,” Verma concluded.