Legal, Payers

CMS proposed rule requires payers to streamline prior authorizations

The rule would require payers in the Medicaid, CHIP and QHP programs to build and maintain application programing interfaces to improve data exchange and the prior authorization process. But the rule does not include Medicare Advantage plans, which the American Hospital Association called "disappointing."

The Centers for Medicare & Medicaid Services issued a proposed rule that would require payers in certain programs to build application programming interfaces to enhance data exchange with providers and patients and simplify the prior authorization process.

Per the proposed rule, payers in the Medicaid, Children’s Health Insurance Program and Qualified Health Plan programs will have to implement and maintain APIs using the Health Level 7 Fast Healthcare Interoperability Resources standard.

“This proposed rule ushers in a new era of quality and lower costs in healthcare as payers and providers will now have access to complete patient histories, reducing unnecessary care and allowing for more coordinated and seamless patient care,” said CMS Administrator Seema Verma in a press release. “Each element of this proposed rule would play a key role in reducing onerous administrative burden on our frontline providers while improving patient access to health information.”

The rule includes five proposals:

1. Maintain a patient access API that would include information about a patient’s pending and active prior authorization decisions, starting Jan. 1, 2023.

2. Build and maintain a provider access API for payer-to-provider sharing of claims and encounter data as well as pending and active prior authorization decisions starting Jan. 1, 2023.

3. Alleviate the administrative burden of prior authorizations by implementing new policies, including requiring payers to provide a specific reason for any denial and shortening the prior authorization window to 72 hours for urgent requests and seven calendar days for standard requests.

4. Create and maintain a FHIR-based payer-to-payer API for exchanging patient data, which would allow patients to take their health information with them when they move from one payer to another.

5. Adopt health IT standards and implementation specifications, proposed by the Office of the National Coordinator for Health IT, to deploy the required APIs.

The new proposed rule builds on the Interoperability and Patient Access final rule published in May.

“Whereas our earlier rule focused on getting health data into the hands of patients, today’s rule is distinctive and groundbreaking because it greases the data exchange wheels between different payers, as well as between payers and providers,” Verma said in a blog post.

But the rule does not include Medicare Advantage plans, which is “deeply disappointing,” the American Hospital Association said in a statement.

“The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care,” the association said. “We are deeply disappointed, however, that CMS chose not to include Medicare Advantage plans, many of which have implemented abusive prior authorization practices, as documented in our recent report. We urge the agency to reconsider and hold Medicare Advantage plans accountable to the same standards.”

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, expressed a similar sentiment on Twitter.

CMS is accepting comments on the rule through Jan. 4, 2021. It has also issued requests for feedback on five specific topics, including how to increase adoption of standards related to social risk data.

Photo credit: Piotrekswat, Getty Images

 

 

 

 

 

 

 

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