CMS proposes conflicting rules for reforming prior authorizations

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Physicians and health care experts want Medicare to lead reforms to the time-consuming prior authorization (PA) process that delays patient care.

But too much reform could make the problem worse, not better.

The U.S. Centers for Medicare and Medicaid Services (CMS) has two proposals for PA rule changes. But they conflict with each other, so instead of streamlining the consultation process with physicians and health insurers to offer patient care, CMS might do just the opposite.

That’s according to the American Medical Association (AMA), the American Hospital Association (AHA), the AHIP health insurance provider trade group, and the Blue Cross Blue Shield Association. The health organizations cowrote a letter to CMS Administrator Chiquita Brooks-LaSure asking the federal regulators to sort through potentially conflicting rule changes.

AHIP said there is a mismatch between the Administrative Simplification proposed rule and the Interoperability and Prior Authorization rule. Both have been published in the Federal Register daily journal of the U.S. Government.

The health organizations said they appreciate CMS’s December 2022 notice of proposed rule making (NPRM) that would adopt new electronic transmission standards for health care attachments.

“We also applaud CMS’ focus on reforming prior authorization (PA) and share the administration’s goals of ensuring timely access to care for patients and minimizing manual paperwork for all health care stakeholders,” said the letter from AMA, AHA, and AHIP. “However, our organizations urge CMS to not proceed with implementing the PA attachment standards provisions of the NPRM due to conflicting regulatory proposals that would set the stage for multiple PA electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate.”

The proposed electronic standards align with those recommended by the National Committee on Vital and Health Statistics in 2016. But since then, “there have been significant developments in both the technology and regulatory spaces,” the letter said.

Now the proposed CMS rules have conflicting provisions that would establish different standards and workflows to complete PAs, depending on the type of health plan. That would result in “widespread industry confusion; slow implementation;” and additional expenses for new technology to meet the federal requirements, the health organizations said.

It was unclear what CMS’ response would be. The medical organizations began publicizing the conflicting rules this week, but CMS did not address the issue in its policy and news update published July 28.