ACP supports CMS proposal to improve prior authorization process

The ACP has commended CMS’ proposal to require payers to streamline the prior authorization process to reduce delays in patient care and expand access.

“Current approaches to prior authorization cause unnecessary delays in patient care and burdensome administrative roadblocks that prevent physicians from spending more time caring for their patients,” ACP President Ryan D. Mire, MD, said in a press release.

The proposed rule would require certain payers to implement an electronic prior authorization process, CMS said in its own press release. Payers would also need to shorten the time frame in which they send responses. A decision on urgent prior authorization requests would need to be sent within 72 hours, and on nonurgent requests, within 7 calendar days. This proposal is “twice as fast” as current response time limits, CMS said.

Payers would additionally need to give specific reasons for denials and provide prior authorization metrics.

Certain payers would also be required to enable data exchanges from one to another in the event a patient switches payers or has concurrent coverage, allowing for a streamlined health record.

Mire noted that while the ACP would like to see the improvements implemented by all payer categories, those that would be covered under the CMS rule include:

• Medicare Advantage organizations;
• state Medicare and Children’s Health Insurance Program (CHIP) fee-for-service programs;
• Medicaid managed care plans and CHIP managed care entities; and
• Qualified Health Plan issuers on the Federally-facilitated Exchanges.

The current prior authorization process has previously garnered negative attention from physicians. In a 2021 AMA survey, 93% of physicians reported that the process causes delays in patient care, with 42% and 14% labeling them as occurring “sometimes” and “often,” respectively.

Additionally, 88% described the burden associated with prior authorization as high or extremely high, while 91% perceived the process as having a somewhat or significantly negative impact on patient clinical outcomes.

“This rule is an important step forward in protecting patients from unnecessary delays in care and reducing administrative burdens on physicians,” Mire said.

He called on CMS to finalize the proposals with “the strongest possible policies for ensuring physicians’ ability to provide seamless evidence-based care for their patients without unnecessary administrative delays.”

References:

• Advancing interoperability and improving prior authorization processes proposed rule CMS-0057-P: Fact sheet. https://www.cms.gov/newsroom/fact-sheets/advancing-interoperability-and-improving-prior-authorization-processes-proposed-rule-cms-0057-p-fact. Published Dec. 6, 2022. Accessed Dec. 8, 2022.
• 2021 AMA prior authorization (PA) physician survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. Accessed Dec. 8, 2022.
• CMS proposes rule to expand access to health information and improve the prior authorization process. https://www.cms.gov/newsroom/press-releases/cms-proposes-rule-expand-access-health-information-and-improve-prior-authorization-process. Published Dec. 6, 2022. Accessed Dec. 8, 2022.
• Internal medicine physicians welcome improvements to prior authorization processes. https://www.acponline.org/acp-newsroom/internal-medicine-physicians-welcome-improvements-to-prior-authorization-processes. Published Dec. 7, 2022. Accessed Dec. 8, 2022.