CMS proposes rule to streamline pre-authorization and require justification for denials

CMS has proposed new rules intended to improve access to health information and “streamline” processes related to prior authorization, according to a press release from the agency.

“CMS is committed to increasing access to quality care and making it easier for clinicians to deliver that care,” Chiquita Brooks –LaSure, a CMS administrator, said in the statement. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote the sharing of healthcare data to improve the care experience between providers, patients and caregivers, which would help us address avoidable delays in patient care and achieve better health outcomes. for everyone.”

The proposed rules require providers to institute a standard “Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR)” application programming interface, to facilitate the processing of electronic prior authorizations, the statement said. In addition, some payers will be required to include a rationale when denying requests, publish pre-authorization actions, and respond to requests in a timely manner. Urgent requests should be answered within 72 hours, while standard requests should be answered within 7 working days, according to the statement.

Eligible healthcare facilities could also add a new electronic prior authorization measure through Medicare’s Interoperability Promotion Program and for the merit-based incentive payment system.

According to the statement, the new rules would promote higher quality patient care while forcing providers to navigate with fewer hurdles, but their true impact is uncertain.

“I suspect the overall effects will be minimal,” Michael Putman, MD, MSc, of the Medical College of Wisconsin, Healio told. “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 justify their denials is a step forward and I could see it reducing some of the more capricious and arbitrary denials that occur.”

Most cases (95%) of requests are approved, Putman said, but the remaining 5% most likely represent needed care that is being denied. Even in cases where the majority of applications are approved, the system represents a “substantial” drain on the system and providers, he said.

Once approved, the rules will apply to Medicare Advantage organizations, state Medicaid and children’s health insurance programs, Medicaid-administered plans, organizations operated by the Children’s Health Insurance program, and issuers of qualified health plans on federal scholarships, CMS said in the release.

The rules can be viewed online and comments can be submitted until March 13.

“The CMS changes are a welcome step forward, but ultimately the process will stick and the damage it causes will continue,” Putman said.