What you need to know about proposed changes to prior authorizations
Prior authorizations. They are one of many challenges that medical practices face on a daily basis. What’s so hard about them? They’re time-consuming, vary from payer to payer, and resource-intensive to manage. Fortunately, some of this may change for the better thanks to a new proposed rule from the Centers for Medicare & Medicaid Services (CMS) aimed at improving and streamlining the process. The goal? To lessen the burden of prior authorizations. This article summarizes key aspects of the rule so medical practices can begin to prepare.
1. Certain payers must implement an electronic prior authorization process.
Currently, some—but not all—payers permit electronic prior authorizations. However, if finalized, the CMS rule would require many more payers to do so using an application program interface (API).
Here’s how it would work: The API would query a payer’s prior authorization documentation requirements and make those requirements available within the provider’s workflow. It would then support the automated compilation of important information from the provider’s system, including necessary data elements to populate a HIPAA-compliant prior authorization. Finally, it would enable payers to compile specific responses regarding the status of the prior authorization, including information about the reason for a denial.
2. Certain payers must respond to prior authorizations in a timelier manner.
Medical practices frequently lament the amount of time it takes to receive a payer response to a request for prior authorization. The good news? If finalized, the CMS rule would require impacted payers to make prior authorization decisions as expeditiously as a patient’s health condition requires, but no later than seven calendar days for standard requests and in some cases as quickly as 72 hours unless state law requires a shorter minimum timeframe.
3. Certain payers must publicly report certain metrics about their prior authorization process for transparency.
If finalized, medical practices, consumers, and others would have much greater insight into each payer’s prior authorization process, including information such as:
All items and services that require prior authorization
Percentage of standard prior authorization requests that were approved, denied, and approved after appeal
Percentage of prior authorization requests for which the timeframe for review was extended (and the request was approved)
Percentage of expedited prior authorization requests that were approved and denied
Average and median time that elapsed between the submission of a request and a determination (for standard as well as expedited prior authorizations)
4. CMS seeks feedback on how it can streamline prior authorizations for maternal healthcare.
Specifically, CMS seeks input and feedback regarding the following questions:
Should timeframes for prior authorization be expedited in cases related to prenatal and perinatal care?
Should prior authorizations carry over from one payer to another when a patient changes payers during the pregnancy?
How have prior authorization processes impact maternal healthcare?
5. CMS proposes a new measure for electronic prior authorization as part of its Merit Based Incentive Payment System (MIPS).
More specifically, CMS proposes a new measure for eligible clinicians under the Promoting Interoperability performance category of MIPS beginning with the performance period/EHR reporting period in calendar year 2026. The goal? To incentivize MIPS eligible clinicians to implement and use electronic prior authorization and the corresponding API.
How to prepare
As medical practices review the CMS proposed rule, it may be helpful to consider these steps:
Comment on the proposed rule. What do you think is a reasonable timeframe for payers to respond to prior authorization requests? What other information, if any, would you like payers to report publicly? The deadline to submit comments is March 13, 2023.
Evaluate your options. Does your current EHR and practice management vendor offer the ability to send electronic prior authorization requests? If not, what is the vendor’s plan to do so in the future?
Ask critical questions. If CMS finalizes a MIPS measure for prior authorizations, would it make sense for your medical practice to report it based on your volume of prior authorization requests? Why or why not?
Conclusion
Start conversations now about the potential impact of this rule on your medical practice. It’s all good news—and practices should start talking about how to leverage the changes. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
Editor’s note: As proposed, the CMS rule generally only applies to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP-managed care entities, and Qualified Health Plan issues on the federally-facilitated exchanges.
