Payers And Provider Groups Laud CMS’ New Authorization Rule

Payers and providers alike have voiced their support for a proposed CMS rule that would impose new obligations on some health insurance providers in an effort to streamline the prior authorization process.

Provider organizations, however, maintain that more work needs to be done before Medicare Advantage plans are fully regulated.

Prior authorization, in which a doctor must first get approval from an insurance company for a certain treatment before providing it, had been a frequent target of criticism – from both hospitals and health insurers – directed at the Trump administration. But the latest rule is receiving a much more positive response from the healthcare industry.

CEO of insurance lobby AHIP, Matt Eyles, praised CMS for prioritizing patients with this rule, which gives them the freedom to share their data with whichever institution they feel comfortable with.

AHIP expressed its delight that hospitals and physicians would be incited to use electronic prior authorization processes in order to attain Medicare’s quality benchmarks in some areas, but it also urged the CMS to take additional measures to safeguard patients’ health information when it was shared with organizations not bound by HIPAA’s regulations.

“While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization’s essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community’s work streamlining this clinical tool to better serve its 30 million diverse enrollees,” stated Mary Beth Donahue, CEO of the Better Medicare Alliance, which represents MA plans.

Donahue also praised the rule’s provisions for data exchange, which call for payers to create and maintain APIs to facilitate the sharing of data with patients, providers, and one another.

Health insurance companies had concerns about the original rule’s two-year deadline for API creation, but the CMS‘s new proposal pushes the deadline out to four years. Providers, meanwhile, were pleased by the new rule’s regulatory plans for Medicare Advantage. Prior authorization was not required for common MA plans under the old 2020 rule.

According to CMS, the proposed policies in this rule will increase access to health data, which will in turn support higher-quality care for patients with fewer interruptions. Under the policy, the Patient Access API would be expanded to include data about previous authorization decisions. In addition, it will allow for the creation of longitudinal patient records by necessitating the exchange of patient data between payers via a payer-to-payer FHIR API whenever a patient changes insurance providers.

In April, the HHS Office of Inspector General issued a report concluding that some MA plans routinely denied prior authorization requests, despite their compliance with Medicare coverage regulations. The OIG conducted an audit in 2018 and found that, following an appeal, Medicare Advantage plans ultimately granted three-quarters of the requests that were initially denied.

Prior authorization is a frequent source of contention between payers and providers, and it is increasingly the responsibility of legislators and policymakers to find a solution to this problem. Doctors argue that the process slows down healthcare services and contributes to burnout, while health insurers say it is the need of the hour, as it helps cut down unnecessary healthcare expenditures.