The proposed rule seeks to reduce administrative burdens and address delays in patient care.
The Centers for Medicare & Medicaid Services (CMS) announced a proposed rule on Dec. 6, 2022, aimed at improving the prior authorization process and interoperability between providers, payers, and patients. The Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P) seeks to improve the exchange of health information and streamline processes related to prior authorization for medical items and services. Under the proposed rule, certain payers would be required to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent. Certain payers would also be required to implement processes that would ensure data exchange between payers is available when patients change payers or have concurrent coverage.
Meeting the Challenges of Prior Authorization
Simply put, prior authorization by a health insurance company confirms that a patient’s health insurance will cover a provider’s prescription; however, the process of applying for prior authorization is not that simple. The process is time-consuming for providers and support staff and can lead to delays in patient care. Patients who experience a delay in treatment or receiving needed medication can experience adverse medical outcomes and/or lower-quality healthcare. More drugs than ever before require prior authorization, as well, and each insurance plan has its own processes and policies, making it challenging to stay current with changing requirements. And since failure to obtain authorization beforehand can mean a practice doesn’t receive payment, practices can suffer from loss of revenue if an insurer denies coverage.
The recent proposed rule would address challenges with the prior authorization process faced by providers and patients. 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
- Requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests, which is twice as fast as the existing Medicare Advantage (MA) response time limit
- 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
Improving Access to Health Information
Proposed policies under the rule would also enable improved access to healthcare data, supporting higher-quality care for patients with fewer disruptions. These policies include:
- Expanding the current patient access API to include information about prior authorization decisions
- Allowing providers to access their patients’ data by requiring payers to build and maintain a provider Access FHIR® API to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship
- Creating longitudinal patient records by requiring payers to exchange patient data using a payer-to-payer FHIR® API when a patient moves between payers or has concurrent payers
These proposed requirements would generally apply to MA organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP-managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs), promoting alignment across coverage types. CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals over $15 billion over a 10-year period.
CMS’ proposed rule not only aims to reduce administration burden on clinicians but also to improve patient care and satisfaction by including five requests for information related to standards for social risk factor data, the electronic exchange of behavioral health information among behavioral health providers, improving the exchange of medical documentation between certain providers in the Medicare Fee-for-Service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interoperability can play in improving maternal health outcomes. You can read the full proposed rule here. The deadline to submit comments is March 13, 2023.