Providers push CMS to enact prior authorization reforms

Photo: Emir Memedovski/Getty Images

Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services, and U.S. Surgeon General Vice Admiral Vivek H. Murthy recently convened an in-person roundtable discussion on reforming prior authorization in federally-sponsored healthcare programs, at which providers pressed CMS to finalize the reforms to alleviate administrative burdens.

The Biden administration has said it's looking to remedy documented abuses in the prior authorization program and ensure patients' timely access to medically necessary care.

Many of the provider attendees belonged to the Alliance of Specialty Medicine, and they echoed the call for the federal government to codify and finalize the prior authorization reforms.

"Prior authorization is a barrier to care that profoundly harms patients," said Dr. Eugene Y. Rhee, public policy chair of the American Urological Association, by statement. "The AUA applauds CMS for the opportunity to participate in today's dialogue about how we can remove this barrier so that patients can get the care they need when they need it. Ongoing communication is key to ensuring CMS understands and addresses the challenges physicians and their patients face every day."

Dr. Shivan Mehta, a gastroenterologist who attended the meeting for the Alliance, said, "We know that health disparities exist in many GI conditions and diseases, and prior authorization only exacerbates this problem. The solutions that HHS is offering will make a difference in ensuring patients can get the care they need when they need it."

WHAT'S THE IMPACT

The Alliance has been a long-time proponent of reform to prior authorization. The group said the program has devolved into a "cumbersome process" that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients.

The process for obtaining approval is lengthy and typically requires physicians or their staff to spend the equivalent of two or more days each week negotiating with insurance companies -- time that would better be spent taking care of patients, the Alliance said. It added that patients experience significant barriers to medically necessary care due to prior authorization requirements for items and services that are eventually routinely approved.

The Alliance recently released a survey of its physician members about prior authorization and other utilization review practices. Respondents overwhelmingly indicated that the use of prior authorization has increased in the last five years across all categories of services and treatments.

According to the survey, more than 93% of respondents answered that PA has increased for procedures. More than 83% responded that PA has increased for diagnostic tools, such as labs and basic imaging; 92% reported that PA has had a negative impact on patients; and 66% said PA has increased for prescription drugs, with physicians noting that even many generic medications now require pre-approvals.

THE LARGER TREND

In a press briefing held on January 17, the same day as the roundtable, Brooks-LaSure and Murthy outlined changes that will be made to speed up and align the prior authorization process across all payers. Murthy called prior authorization a burden that adds to physician burnout.

A proposed rule by CMS would require certain payers to implement an electronic prior authorization process for attachments and signatures. It would require implementation of a Health Level 7 (HL7) Fast Healthcare Interoperability Resources FHIR standard Application Programming Interface (API) to support electronic prior authorization.

Certain payers would be required to implement standards enabling data exchange from one payer to another when a patient changes or has concurrent insurance coverage – that's to help ensure that complete patient records are available throughout the transition, CMS said.

The proposed rule would also require insurers to provide reasons for the denial. The third change would align prior authorization policy across Medicare, Medicare Advantage, Medicaid, CHIP and Affordable Care Act marketplace plans, according to Brooks-LaSure.

The rule would generally apply to Medicare Advantage organizations, state Medicaid and CHIP agencies, Medicaid managed care plans, CHIP-managed care entities, and Qualified Health Plan issuers on the federally-facilitated exchanges, promoting alignment across coverage types.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com