LeadingAge Supports Proposal to Reduce Prior Authorization Burden

Regulation | January 05, 2021 | by Nicole Fallon

The Center for Medicare and Medicaid Services (CMS) proposed rules in early December 2020 that would require certain payers and plans to adopt new technology and processes to improve the prior authorization process through the use of Application Program Interfaces (APIs) and promote patient access to health information. They are part of a larger initiative to move the health care system toward greater interoperability, reduce provider burden and improve patient access to health information. LeadingAge offered its support for these efforts and some suggestions for additional improvements via the rule comment process.

Initially, the proposed new requirements will only apply to Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and some health insurance exchange plans. CMS indicates that nothing in the proposed rules precludes Medicare Advantage organizations from also implementing these policies but for now CMS will continue to evaluate whether to extend these requirements to MA organizations. LeadingAge encouraged them to do so noting the issues providers encounter with getting MA plans to timely approve prior authorizations. In addition, should the rules be finalized, CMS said it would aim to implement these requirements for Medicare FFS programs

The proposed rules would:

  • Require payers, as previously noted, to build and maintain Provider APIs that would allow for data sharing –including claims, encounter, and some clinical data -- and the electronic processing of prior authorization requests as soon as January 1, 2023.
  • Make the prior authorization process more efficient and transparent by developing APIs that can integrate with a provider’s electronic health record and workflow to request prior authorizations and track their status. This information would also be available to patients who opt-in.  
  • Require applicable payers to give a reason for denials of prior authorizations.
  • Establish a timeframe in which prior authorization decisions must be made through these payers – 72 hours for urgent requests and 7 calendar days for standard requests.
  • Track prior authorization measures such as number approved or denied, the average time between submission and determination, and others. These data will first be reported in March 2023.
  • Build upon prior regulations related to interoperability and patient access to electronic health information by establishing a Patient API. The proposed rules seek to add some additional privacy protections for patient health information to these initial requirements and also provide transparency about the prior authorization process to the consumer by including this information in their records. 
  • Seek to also have payers exchange information to ease transitions for consumers when they change plans.

CMS also sought information from stakeholders on several topics including how to reduce the use of fax technology and adoption of the proposed API electronic systems.

Overall, the onus will be on payers to develop the new systems, which hopefully will reduce the administrative burden for providers who must pursue prior authorizations for certain services.