CMS Proposed a Rule for Improving Prior Authorizations

1. CMS Proposed a Rule for Improving Prior Authorizations Medical Billers and Coders

2. CMS recently proposed a rule to improve prior authorizations processes by reducing the burden on providers and patients. This proposed rule would place new requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of health care data, and streamline processes related to prior authorization. The rule would require increased patient electronic access to their health care information and would improve the electronic exchange of health information among payers, providers, and patients. Together, these policies would play a key role in reducing overall payer and provider burden and improving patient access to health information. This rule includes five sets of proposals and five requests for information. These prior authorization policies are proposed to take effect on January 1, 2023, with the initial set of metrics proposed to be reported by March 31, 2023. In this article, we shared only one proposal named ‘Documentation and Prior Authorization Burden Reduction through APIs’

3. Documentation and Prior Authorization Burden Reduction through APIs Prior authorization is an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply. The prior authorization request is made before those medical services or items are rendered. While prior authorization has its benefits, patients, providers, and payers alike have experienced burdens from it. And, it has been identified as a major source of provider burnout. Providers expend staff resources to identify prior authorization requirements and navigate the submission and approval processes, resources that could otherwise be directed to clinical care, and processes that vary across payers. Patients may unnecessarily pay out-of-pocket or abandon treatment altogether when prior authorization is delayed. In an attempt to alleviate some of the administrative burdens of prior authorization and to improve the patient experience, CMS is proposing a number of policies to help make the prior authorization process more efficient and transparent.

4. Document Requirement Lookup Service (DRLS) API: CMS is proposing to require impacted payers to build and maintain an FHIR-enabled DRLS API, that could be integrated with a provider’s electronic health record (EHR)- to allow providers to electronically locate prior authorization requirements for each specific payer from within the provider’s workflow. • Prior Authorization Support (PAS) API: CMS is proposing to require impacted payers to build and maintain an FHIR-enabled electronic Prior Authorization Support API that has the capability to send prior authorization requests and receive responses electronically within their existing workflow (while maintaining the integrity of the HIPAA transaction standards). • Denial Reason: CMS is proposing to require impacted payers to include a specific reason for denial when denying a prior authorization request, regardless of the method used to send the prior authorization decision, to facilitate better communication and understanding between the provider and payer.

5. Shorter Prior Authorization Timeframes: CMS is proposing to require impacted payers (not including QHP issuers on the FFEs) to send prior authorization decisions within 72 hours for urgent requests and 7 calendar days for standard requests. • Prior Authorization Metrics: CMS is proposing to require impacted payers publicly report data about their prior authorization process, such as the percent of prior authorization requests approved, denied, and ultimately approved after appeal, and the average time between submission and determination, to improve transparency into the prior authorization process, which will help patients understand.

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