Dive Brief:
- The CMS is launching a new effort to speed progress on electronic prior authorization as the healthcare sector prepares to implement new requirements on digital pre-approvals next year.
- Thirty healthcare organizations — including providers like Cleveland Clinic and Providence; electronic health record developers Epic and Oracle Health; and health data networks like CommonWell and Kno2 — signed onto the pledge to address challenges in electronic prior authorization, the CMS said Wednesday.
- They’ll work with payers that have already joined the agency’s Health Tech Ecosystem to integrate electronic prior authorization in clinical and administrative systems, reduce manual processes like faxes and more easily track authorization status and decisions.
Dive Insight:
Prior authorization, where clinicians have to receive approval from insurers before offering certain services or medications, has become a controversial practice among providers, who argue it creates significant administrative burdens and delays necessary medical care.
Electronic prior authorization could help, the CMS says. Decisions should be reached more quickly, reducing the amount of time providers spend on paperwork or conducting duplicative tests to meet requirements, according to the agency.
But physicians still most commonly use the phone to complete prior authorizations for medical services, according to a survey published this week by the American Medical Association. And only about a quarter said their EHR offers electronic prior authorization for prescriptions.
Meanwhile, the clock is ticking toward a deadline when many providers and insurers will have to make progress toward electronic prior authorization use. Payers will have to implement a standardized application programming interface, rules that allow computer systems to exchange data with one another, for prior authorization by January.
They’ll also have to expand APIs for patient access to prior authorization information, as well as implement APIs for sharing data with providers and other insurers.
The latest pledge should help, allowing healthcare organizations across the sector to work together to address implementation challenges before the requirements go into effect, the CMS said.
Though insurers and providers are making progress in complying with the rule, there’s still work to be done, according to a survey published in March by the Workgroup for Electronic Data Interchange. Ten percent of payers said they hadn’t started work on API requirements, while 33% of providers said they hadn’t begun implementation and testing.
“Prior authorization won’t be fixed by technology alone. It requires the entire healthcare system to work together to solve real-world challenges,” CMS Administrator Dr. Mehmet Oz said in a statement.
The prior authorization pledge is part of the CMS’ Health Tech Ecosystem, an ambitious and wide-ranging partnership launched last year with the private sector that aims to ease health data sharing and increase access to digital health tools.
In April, the agency showcased dozens of health technology products as part of an update on the ecosystem’s work, including tools to help patients collect their data and share their information with new clinicians.
