Providers and payers unite in blasting ‘hastily constructed’ CMS final rule to simplify prior authorization

The Centers for Medicare & Medicaid Services issued a final rule on Friday aimed at easing the burden of onerous prior authorization policies on both patients and providers. Advocates in the physician and payer communities, meanwhile, believe the policy will do little to fix the problem.

Among other provisions, the “CMS Interoperability and Prior Authorization” rule will task certain insurers with granting peers, providers and patients with electronic access to pending PA decisions. Administrator Seema Verma labeled the law as “historic” and said that millions of patients will no longer need to wrangle with fax machines to take claim of their 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,” she said Jan. 15. “This change will reverberate around the healthcare system for years and decades to come.”

The Medical Group Management Association, on the other side, called the legislation a “huge missed opportunity” to address what it believes is the top administrative burden facing practices. CMS’ rule only pertains to Medicaid, the Children’s Health Insurance Program and qualified plans on federally facilitated exchanges.

“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 VP of government affairs for the MGMA, which represents 55,000 practice leaders across the U.S., in radiology and other specialties. “This failure will require practices to continue deploying multiple, manual prior authorization workflows, including using phone, fax and payer web portals.”

Under the final rule, certain payers will be required to implement technology that allow radiologists and other providers to know, in advance, what documentation might be needed for a coverage request. CMS said its goal is to streamline the process, allowing docs to send requests and receive responses directly from the electronic health record or practice management system. Plans will have up to 72 hours to make PA decisions on any urgent request and seven for less-pressing situations.

Alongside physicians, the payer community also slammed this new policy on Friday. America’s Health Insurance Plans President and CEO Matt Eyles called the leadup to Friday the shortest rulemaking on a major healthcare legislation in recent memory, granting only 14 days for comment. The federal agency first released its initial proposal in December, received thousands of pages in public feedback from hundreds of stakeholders, and took just nine days to review them. All this, with a rule that’s estimated to cost some $3 billion to implement, he noted.

“Unfortunately, today’s final rule from CMS is largely a series of empty promises,” Eyles said. “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 bridges to nowhere by failing to establish comparable requirements for providers or their IT vendors to use the technologies."

The rule is set to be implemented in phases from 2023 through 2024. For more, you can check out this federal fact sheet and read the full 433 pages here.