ACR applauds proposed prior authorization changes, urges shorter waits for urgent requests
Click Here to Manage Email Alerts
The American College of Rheumatology has applauded CMS for recognizing, in its 2023 proposed rule on prior authorization, the “undue burden” the practice places on providers, according to a press release.
CMS in December proposed new rules intended to “streamline” the prior authorization process and improve access to health information.
“Prior authorizations put an undue burden on providers seeking to do what is in the best interests of their patients,” ACR President Douglas White, MD, PhD, said in the release. “The ACR appreciates the consideration that went into this comprehensive rule, and we look forward to working with CMS to implement policies related to improving the prior authorization process.”
The proposed rule change would require providers institute a “Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR)” application in order to streamline electronic processing of prior authorizations. In addition, specific payers will need to supply rationales for request denials. Finally, the rule change stipulates a 72-hour deadline for urgent requests.
The rules are available to review online, and comments may be submitted through March 13.
The ACR’s comment letter also includes recommendations to improve the impact of the proposed rule changes. Those changes include:
- Expanding prior authorization guidance to include “all utilization management tools for services and therapeutics, including step therapy policies.”
- Reducing the timeline for urgent requests from 72 to 24 hours.
- Including more sub-regulatory guidance regarding step therapy that will not interrupt patient access to needed therapies.
- Maintaining the necessity of payers to justify denials.
- Removing e-prior authorization measures for MIPS-eligible providers under the performance improvement category until such a time that electronic health records can report this information “without additional burden to providers.”
According to a survey published by the American Medical Association, most physicians believe the toll that prior authorization exerts far exceeds any purported benefits. The AMA’s physician survey found that 86% of respondents reported that prior authorizations led to higher overall health care use, resulting in “unnecessary waste rather than cost-savings.”
The surveyed physicians additionally reported that initial therapy attempts, office visits and emerging urgent situations increase health care cost. In all, 64% of surveyed providers said that prior authorizations lead to “ineffective initial treatments.” Meanwhile, 62% of surveyed providers reported that these policies led to additional clinic visits, and just 46% reported that these policies led to necessary “urgent or emergency care for patients.”
“Prior authorizations are supposed to ensure that the health care system is driven by evidence-based medicine to make sure proper treatment is administered without unnecessary costs,” White wrote in the ACR comment letter to CMS. “Sadly, prior authorizations have become a way to hinder, deter or prevent the services and treatments that allow providers to treat their patients effectively. We hope these policies will provide relief for providers while also ensuring patients receive the care they need.”
References:
Toll from prior authorization exceeds alleged benefits, say physicians. https://www.ama-assn.org/press-center/press-releases/toll-prior-authorization-exceeds-alleged-benefits-say-physicians. March 13, 2023. Accessed March 13, 2023.
Collapse
Press Release
Click Here to Manage Email Alerts