CMS Unveils Contentious Prior Authorization Reform Rule Proposals

Prior Authorization Reform Rule Proposals

Physicians and healthcare experts are urging Medicare to lead reforms in the time-consuming prior authorization (PA) process, which often causes delays in patient care. However, they caution against excessive reform, as it could exacerbate the problem rather than improving it.

The U.S. Centers for Medicare and Medicaid Services (CMS) have put forth two proposals for changes to the PA rules. Unfortunately, these proposals conflict with each other, potentially hindering the effort to streamline the consultation process between physicians and health insurers for the benefit of patient care. Instead of facilitating the process, CMS might inadvertently create more challenges.

The American Medical Association (AMA), the American Hospital Association (AHA), the AHIP health insurance provider trade group, and the Blue Cross Blue Shield Association have jointly written a letter to CMS Administrator, requesting federal regulators to address these potentially conflicting rule changes.

AHIP has pointed out a mismatch between the Administrative Simplification proposed rule and the Interoperability and Prior Authorization rule, both of which have been published in the Federal Register daily journal of the U.S. Government.

The health organizations expressed their gratitude for CMS’s December 2022 notice of proposed rulemaking (NPRM) aimed at adopting new electronic transmission standards for health care attachments. They also applauded CMS’s focus on reforming prior authorization (PA) to ensure timely access to care for patients and reduce manual paperwork for stakeholders in the healthcare industry.

However, the organizations urged CMS not to proceed with implementing the PA attachment standards provisions of the NPRM. This caution arises from conflicting regulatory proposals that could result in multiple PA electronic standards and workflows, leading to the same costly administrative burdens that the simplification efforts seek to alleviate.

The proposed electronic standards were initially aligned with recommendations from the National Committee on Vital and Health Statistics in 2016. Nonetheless, since then, significant developments have occurred in both technology and regulatory domains.

The current proposed CMS rules contain conflicting provisions, establishing different standards and workflows for completing PAs based on the type of health plan. This situation would lead to widespread confusion in the industry, slow implementation, and additional expenses for new technology to meet federal requirements, as per the concerns raised by the health organizations.

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