Providers push CMS for pre-authorization reforms

Photo: Emir Memedowski/Getty Images

Chiquita Brooks-Lasur, Administrator of the Centers for Medicare and Medicaid Services, and US Surgeon General Vice Admiral Vivek H. Merty recently held a face-to-face roundtable discussion on prior authorization reform in government-sponsored health care programs, in which service providers pressed CMS to complete the reforms to reduce the administrative burden.

The Biden administration said it is committed to correcting documented violations in the prior authorization program and ensuring that patients have timely access to medically necessary care.

Many of the participating vendors belonged to the Specialty Medicine Alliance and supported the call for the federal government to systematize and complete the prior authorization reforms.

“Prior authorization is a barrier to treatment that causes serious harm to patients,” said Dr. Eugene Rhee, chairman of public policy for the American Urological Association. “AUA welcomes the opportunity for CMS to be part of today’s dialogue on how we can remove this barrier so that patients can get the care they need, when they need it. Continuous communication is key for CMS to understand and solve the problems of physicians and their patients. face every day.

Dr. Shivan Mehta, a gastroenterologist who attended the Alliance meeting, said: “We know there are health disparities in many gastrointestinal conditions and diseases, and pre-clearance only exacerbates this problem. ensuring that patients can get the care they need when they need it.”

WHAT INFLUENCES

The Alliance has long advocated reform of the prior authorization system. The group said the program has become a “burdensome process” that requires doctors to obtain prior authorization for treatments or tests before providing care to their patients.

The approval process is lengthy and typically requires doctors or their staff to spend the equivalent of two or more days a week negotiating with insurance companies — time that would be better spent caring for patients, the Alliance said. He added that patients face significant barriers to getting medically needed care due to prior authorization requirements for items and services that are usually eventually approved.

The Alliance recently published a survey of its member physicians about prior authorization and other methods of verifying use. The vast majority of respondents indicated that the use of prior authorization has increased over the past five years across all service and treatment categories.

According to the survey, more than 93% of respondents answered that FA increased by procedures. Over 83% responded that PA has increased for diagnostic tools such as laboratory and basic imaging; 92% reported that PA has a negative effect on patients; and 66% said PA has increased for prescription drugs, with physicians noting that even many generic drugs now require prior approval.

BIG TREND

At a press briefing on January 17, the same day as the roundtable, Brooks-Lasur and Murthy spoke about changes that will be made to speed up and harmonize the pre-authorization process for all payers. Murthy called pre-clearance a burden that exacerbates physician burnout.

The proposed CMS rule would require some payers to implement an electronic pre-authorization process for attachments and signatures. Implementation of the standard Health Level 7 (HL7) Fast Healthcare Interoperability Resources FHIR Application Programming Interface (API) will be required to support electronic pre-authorization.

Some payers will need to implement standards to allow data to be exchanged from one payer to another when a patient changes or has concurrent coverage, CMS said, to help ensure patients’ complete medical records are available throughout the transition.

The proposed rule would also require insurers to explain the reasons for the denial. According to Brooks-LaSure, the third change will align the pre-authorization policies for Marketplace Medicare, Medicare Advantage, Medicaid, CHIP, and Affordable Care Act plans.

This rule generally applies to Medicare Advantage Organizations, State Medicaid and CHIP Agencies, Medicaid Managed Care Plans, CHIP Managed Care Institutions, and Issuers of Qualified Care Plans on federal exchanges, facilitating harmonization of coverage types.

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