CMS proposes new rules to address prior authorization and reduce burden on patients and providers

Dec. 11, 2020

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve the electronic exchange of healthcare data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients.

By both increasing data flow, and reducing burden, this proposed rule would give providers more time to focus on their patients and provide better quality care. The proposed rule aims to improve this for patients navigating care. The proposed rule would build on the Interoperability and Patient Access final rule published by the CMS in May.

The rule would require payers in Medicaid, CHIP and QHP programs to build application programming interfaces (APIs) to support data exchange and prior authorization. APIs allow two systems, or a payer’s system and a third-party app, to communicate and share data electronically. Payers would be required to implement and maintain these APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. The FHIR standard is an innovative technology solution that helps bridge the gaps between systems so both systems can understand and use the data they exchange.

On behalf of the Department of Health and Human Services (HHS), the Office of the National Coordinator for Health IT (ONC) is also proposing to adopt certain standards through an HHS rider on the CMS proposed rule.

Prior authorization is an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply. This process takes place before a service is rendered. The rule proposes significant changes to improve the patient experience and alleviate some of the administrative burden prior authorization causes healthcare providers. Medicaid, CHIP and QHP payers would be required to build and implement FHIR-enabled APIs that could allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or other practice management system. While Medicare Advantage plans are not included in today’s proposals, CMS is considering whether to do so in future rulemaking.

The proposed rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers—the rule proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the FFEs, to issue decisions on urgent requests and seven calendar days for non-urgent requests. Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing. 

These policies, taken together, could lead to fewer prior authorization denials and appeals, while improving communication and understanding between payers, providers, and patients. They are the result of numerous listening sessions with plans and providers aimed at crafting a new process that balances the need for greater efficiency and consistency in prior authorization and its important role in preventing fraud, abuse, and unnecessary expenditures.

Building on that foundational policy, this rule would require impacted payers to implement and maintain a FHIR-based API to exchange patient data as patients move from one payer to another. In this way, patients who would otherwise not have access to their historic health information would be able to bring their information with them when they move from one payer to another and would not lose that information simply because they changed payers. 

These proposed changes would also allow payers, providers and patients to have access to more information including pending and active prior authorization decisions, potentially allowing for fewer repeat prior authorizations, reducing burden and cost, and ensuring patients have better continuity of care.

CMS has the release.