CMS proposes rule to streamline prior authorization, require justification for denials
Click Here to Manage Email Alerts
CMS has proposed new rules intended to improve access to health information and “streamline” processes that are involved with prior authorization, according to a press release from the agency.
“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” Chiquita Brooks-LaSure, an administrator at CMS, said in the 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.”
The proposed rules require providers to institute a “Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR)” standard application programming interface, to facilitate the processing of electronic prior authorizations, the release said. Additionally, certain payers will be required to include rationale when denying requests, publish metrics related to prior authorization and respond to requests in a timely manner. Urgent requests must be processed within 72 hours, while standard requests must be processed within 7 business days, the release said.
Eligible health care settings would also be able to add a new Electronic Prior Authorization measure via the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System.
According to the release, the new rules would support higher quality patient care while requiring providers to navigate with fewer obstacles, but their true impact is not certain.
“I suspect the overall effects will be minimal,” Michael Putman, MD, MSci, of the Medical College of Wisconsin, told Healio. “Prior authorizations are not going away and will continue to consume valuable time and resources that could be spent elsewhere.”
Putman added, “That said, requiring insurance companies to at least give some justification for their denials is a step forward and I could see it reducing some of the more capricious and arbitrary refusals that occur.”
Most cases (95%) of requests are approved, Putman said, but the remaining 5% most likely represent necessary care that is denied. Even in cases where the majority of requests are approved, the system represents a “substantial” drain on the system and the providers, he said.
Upon approval, the rules will apply to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Programs, Medicaid managed plans, Children’s Health Insurance Program-managed organizations and Qualified Health Plan issuers on federal exchanges, CMS said in the release.
The rules are available to review online, and comments may be submitted through March 13.
“The CMS changes are a welcome step forward, but ultimately the process will remain and the harms it causes will continue,” Putman said.
Collapse
Read more about
Click Here to Manage Email Alerts