CMS proposes rule change to speed up prior authorization process

The Medicare prior authorization process could become quicker under a new rule proposed by the U.S. Centers for Medicare & Medicaid Services (CMS).

The new rules also aims to improve patient and provider access to health information, along with a number of other goals, according to the CMS announcement from Dec. 6. It is part of President Joe Biden and his administration’s “ongoing commitment to increasing health data exchange and investing in interoperability,” and, if implemented, could save physicians and hospitals more than $15 billion over a 10-year period, the CMS announcement said.

“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 a news 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.”

What’s new

The draft rule has five key provisions and five requests for information.

Proposals include requiring implementation of a Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard Application Programming Interface (API) to support electronic prior authorization, the CMS announcement said.

They also include requirements for certain payers to:

• Include specific reasons when denying requests
• Publicly report certain prior authorization metrics
• Send decisions within 72 hours for expedited, i.e., urgent, requests, and seven calendar days for standard, i.e., nonurgent requests, which is twice as fast as the existing Medicare Advantage response time limit.

To further support a streamlined prior authorization process, this proposed rule would add a new electronic prior authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the promoting interoperability performance category, according to CMS.

The changes won’t take effect immediately – there’s at least a 90-day comment period lasting till March 13, 2023.

Positive response

Anders Gilberg, senior vice president of government affairs, Medical Group Management Association

The proposal earned praise from the Medical Group Management Association (MGMA) and the American Academy of Family Physicians (AAFP). They noted more work needs to be done to smooth out the prior authorization process, but the proposed rule is a win for the medical organizations’ advocacy.

“An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals. The onerous methods of completing these requests, coupled with the increasing volume is unsustainable,” Anders Gilberg, MGMA senior vice president of government affairs, said in a statement. “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.”

Tochi Iroku-Malize, MD, MPH, MBA, president, American Academy of Family Physicians

AAFP is reviewing the rule and continues advocating for Senate passage of the Improving Seniors’ Timely Access to Care Act, another bill that would affect Medicare Advantage prior authorizations.

“The average physician spends too much time completing prior authorizations – taking time away from patients and potentially creating dangerous care delays,” AAFP President Tochi Iroku-Malize, MD, MPH, MBA, said in a statement. “In a win for AAFP advocacy, we are pleased by HHS’s proposed rule to streamline prior authorization processes, but comprehensive reform is needed to reduce the volume of prior authorizations and ensure patients’ timely access to care. The rule is good news for family physicians and an important first step in alleviating burden and improving access to care.”