CMS moves to ease burden, burnout stemming from onerous prior authorization policies

The Centers for Medicare & Medicaid Services on Thursday introduced policy changes aimed at easing the burden of onerous prior authorization policies.

Under the proposal, payers would be required to implement technology that allows 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 PA process, allowing docs to send requests and receive responses directly from the electronic health record or practice management system.

“Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients,” Administrator Seema Verma said in a statement. “If just a quarter of providers took advantage of the new electronic solutions that this proposal would make available, the proposed rule would save between $1 and $5 billion over the next 10 years.”

One analysis earlier this year highlighted the skyrocketing costs of prior authorization policies that require rads to check first whether an insurer covers a scan or image-guided procedure. In particular, the price to generate a manual PA request increased 60% between 2018 and 2019, at a time when the insurer’s cost dropped.

CMS’ proposal would pertain to payers in Medicaid, the Children’s Health Insurance Program and qualified plans on the exchange. The agency excluded Medicare Advantage plans from Thursday’s rule, but added that it’s considering whether to incorporate them in future rulemaking.

The Medical Group Management Association—which represents 55,000 practice leaders across the U.S., including radiology and other specialties—criticized MA’s absence.

“Today’s proposal makes progress in concept but contains such a glaring omission it may have little effect on reducing the most significant burden faced by medical practices,” Anders Gilberg, MGMA’s senior VP of government affairs, said in a statement. “By excluding Medicare Advantage plans from new prior authorization requirements, CMS fails to ensure widespread adoption of standards that could have a major impact. “

The feds are accepting comments on the proposal until Jan. 4 and hope to implement the policy in 2023. You can read more in this fact sheet and find the full rule here.