WASHINGTON — The reviews are in on a final rule on prior authorization issued Friday by the Centers for Medicare & Medicaid Services (CMS) — and they’re not good.
“Today’s final rule from CMS is largely a series of empty promises,” said Matt Eyles, president and CEO of America’s Health Insurance Plans (AHIP), the lobbying group for health insurers, Friday in a statement. “This shabbily and hastily constructed rule puts a plane in the air before the wings are bolted on by requiring health insurance providers to build these technologies with incomplete and untested instruction manuals. And, despite rushing the rule, this administration requires insurance providers to build expensive IT [information technology] ‘bridges to nowhere’ by failing to establish comparable requirements for providers or their IT vendors to use the technologies.”
“By excluding Medicare Advantage, Medicare fee-for-service, and most commercial payers, the rule will do little to address widespread health plan abuses that delay and deny patient care,” said Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association here, in a statement that also called the final rule a “huge missed opportunity.”
“This failure will require practices to continue deploying multiple, manual prior authorization workflows, including using phone, fax, and payer web portals,” he added.
The rule aims to ease clinician burdens from prior authorization (PA) — requirements by health insurers that providers get authorization for a particular treatment in advance in order for the insurer to reimburse for it. Prior authorization has long been the bane of many providers’ existence, with its accompanying paperwork, faxes, and phone calls. The rule finalized by CMS will require insurers and electronic health record vendors to:
- Build and maintain a Document Requirement Lookup Service application programming interface (API) within the electronic health record, to help identify the PA requirements of specific payers.
- Build and maintain a Fast Healthcare Interoperability Resource-enabled electronic PA support API to send and receive PA requests electronically within their established workflow (while following HIPAA transaction standards).
- Offer a specific reason for a denial of a PA request to “facilitate better communication and understanding between the provider and payer” (this requirement would stand regardless of the method used to request the PA).
- Send PA decisions within 72 hours for an urgent request and 7 days for standard requests.
- Publicly share data about their PA process — for instance, the share of PA requests that are approved, denied, and approved following appeal, and the average time between when a request is made and a determination. “While we are not finalizing the exact metrics, we are finalizing our policy to require payers to report metrics regarding prior authorization on their websites,” the agency said.
Most of the rule takes effect Jan. 1, 2023, although a few provisions become effective a year later.
In a statement, outgoing CMS administrator Seema Verma called the final rule “a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system.”
“Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come,” she said.
But AHIP’s Eyles called the rule “half-baked,” noting that “this administration conducted the shortest rulemaking process on a major healthcare rule that anyone can remember. This unprecedented timeline afforded stakeholders only 14 business days to comment. Miraculously, the administration was able to provide the ‘reviews’ and ‘responses’ in less than 9 business days despite over 250 stakeholders filing thousands of pages of public comments. This was wholly inadequate to allow stakeholders to conduct appropriate analyses and was clearly not consistent with the thoughtful notice-and-comment approach to developing policies that is customarily afforded a rule estimated to cost nearly $3 billion to implement.”
Margaret Murray, CEO of the Association for Community Affiliated Plans (ACAP) here, also faulted the rule for being rushed. “This rule includes numerous new and complex policy changes — some of which ACAP supports — but CMS gave plans an absurdly short time period to consider and create strategies to implement these changes,” Murray said in a statement, adding that “25 days is simply not enough, especially while our plans are prioritizing the ongoing COVID-19 pandemic and forthcoming vaccine distribution efforts.”
“CMS states the intent of this rule is to reduce administrative burden for providers and ensure patients have access to their health information,” said Murray, whose group represents 78 safety-net health plans. “These are worthy goals. But they are not feasible if plans have not been given sufficient time to prepare. HHS [the Department of Health and Human Services] has rushed this rule at every step of the process and provided little more than lip service to the stakeholders who will be left to implement these sweeping changes. Without sufficient time to digest these changes, ACAP calls on the Biden administration to freeze implementation of this regulation and for Congress to consider its rescission by way of the Congressional Review Act.”
Source: MedicalNewsToday.com
