Medicare leaders explain proposals to make prior authorizations easier and faster

Chiquita Brooks-LaSure, CMS adminstrator
_{U.S. Centers for Medicare & Medicaid Services}

Medicare leaders say they’re serious about examining – and speeding up – the prior authorization process for patient treatment.

The issue was part of the 2022 recap and 2023 look ahead in the quarterly stakeholder conference call of Jan. 24 led by Chiquita Brooks-LaSure, administrator for the U.S. Centers for Medicare & Medicaid Services (CMS).

CMS announced the proposed rule changes in December and there is an open comment period that runs into March.

Brooks-LaSure referred to a stakeholder listening session earlier this month and heard about what a difference the new rules could make in the prior authorization process.

“And our goal is really to make sure that people have access to care,” she said. Mary Greene, MD, director of CMS’ Office of Burden Reduction and Health Informatics, agreed and explained why the CMS leaders are considering the proposals.

“Prior authorization is an important utilization management tool but when it's onerous to get through the process, that's a problem for everybody involved,” Greene said. “Patients may unnecessarily pay out of pocket or abandon treatment altogether when prior authorization delays, care. Prior authorization is also a leading cause of burnout among clinicians and payers have to redo work when they don't receive upfront the information they need to make decisions.

“Ensuring prior authorization is efficient, transparent and standardized is critical to ensuring timely access to care,” Greene said.

Prior authorizations

Mary Greene, MD
_{U.S. Centers for Medicare & Medicaid Services}

CMS has proposed a rule change so payers must offer denial reasons and have quicker turnarounds, possibly as short as 48 hours for urgent requests.

The proposal “is intended to enhance patient and provider access to health information and to see streamline prior authorization processes across different sources of healthcare coverage,” Greene said.

“It proposes new requirements on pairs to approve the electronic exchange of health data, electronic prior authorization,” she said. “It also proposes timeframes around how quickly some peers would need to respond to prior authorization requests and require peers to publish certain metrics around the rates, the rates of approval and appeals.”

Supporting documentation

CMS is considering new standards for “health care attachments,” the medical charts, x-rays, and provider notes used for physician referrals.

“Sometimes in the prior authorization process, providers need to send more complete clinical information to payers, such as medical charts or x-rays and documentation for referrals as examples. That's where the attachment proposal comes in,” Greene said. “The attachment proposed rule includes proposals that would adopt standards for health care attachments transactions, and that would support both health care claims transactions and prior authorization transactions.

Making it easier

“So together these two rules, ensure patients, providers, and payers have the information they need to get through the prior authorization process and get to a decision faster so patients can get the care they need more quickly,” Greene said. “It gives patients more visibility into how plans handle prior authorizations and that information might be helpful to patients when they're selecting the health plan they want to join.”

The proposed rules would make the technical approach more standardized across Medicare, Medicaid, and insurance programs available through the Affordable Care Act Marketplace programs. That will make it easier for providers to navigate the prior authorization process, Greene said.