Industry Applauds CMS Prior Authorization Rule, Requests Further Action

Last Wednesday, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will truncate the timeline for prior authorization processes to 72 hours for people who receive health coverage from insurers participating in Medicare Advantage, Medicaid managed care, or the Affordable Care Act exchange.

The CMS Interoperability and Prior Authorization Final Rule specifies that non-urgent pre-approval requests may take no longer than seven days. Insurers also will need to provide reasons for denial of care and report data on their decisions. Modern Healthcare reports that providers are largely in support of the rule, and view it as a necessary update to the approval process.

The American Medical Association (AMA) has long lobbied for prior authorization reform. In a statement, AMA President Jesse M. Ehrenfeld, MD, MPH, championed the final rule as support for efficient transfer of information enabled by electronic prior authorization.

The AMA also appreciates that the rule will significantly enhance transparency around prior authorization by requiring specific denial reasons and public reporting of program metrics as well as requiring that prior authorization information be available to patients to help them become more informed decision makers.

The AMA also applauds the U.S. Department of Health and Human Services’ findings that the changes will save physicians roughly $15 billion over 10 years. It is further explained in an AMA News Wire Podcast that the savings doesn’t even account for lower patient costs that would come with timely delivery of care.

The controversy around prior authorization has frustrated some large private insurers enough that they independently announced internal adjustments to their own prior authorization policy, Wall Street Journal reports.

Insurers voiced cautious approval for the rule via America’s Health Insurance Plans, the country’s largest insurance lobby. In the statement, AHIP championed the benefits of electronic health records in the speedy delivery of care. It also thanked CMS for allowing plans to use a single standard for implementation and called for the Office of the Coordinator for Health Information Technology to require vendors to build electronic prior authorization capabilities into the electronic health record.

We cannot afford to delay any further when it comes to implementing electronic prior authorization capabilities. Let’s work together to ensure that we can provide patients with the best possible healthcare experience while reducing administrative burdens on providers and plans.

According to Medical Economics, a bipartisan group of legislators including some physicians and Senator Kyrsten Sinema (I-Ariz.) issued a joint statement applauding the rule. The statement also urged other members of Congress to pass the Improving Seniors’ Timely Access To Care Act, which would further reduce the wait time for care approval.

This will also enable healthcare providers to focus on delivering better care rather than wasting hours on the phone with insurance companies. While CMS could have gone further, these changes will help bring the antiquated prior authorization system into the 21st century with commonsense changes like a streamlined approval process and increased transparency.