- Major hospital and payer associations put aside their numerous policy differences last week to co-write a letter to the CMS asking the agency to clarify conflicting rules they say would enact different data exchange standards for prior authorization reviews.
- The American Hospital Association, American Medical Association, AHIP and Blue Cross Blue Shield Association sent a letter to the CMS on Thursday arguing that two December proposed rules, if finalized, would “set the stage for multiple [prior authorization] electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate.”
- The Administrative Simplification rule would enact standards around when payers and providers send healthcare attachments to support claims and prior authorization transactions. Meanwhile, the Interoperability and Prior Authorization rule includes different requirements for when government-sponsored insurers such as Medicare Advantage plans share information when processing prior authorization requests.
The CMS has been trying to streamline prior authorization, a process in which physicians request approval from an insurer for medication or treatment before administering it. Payers and providers have long been at odds over prior authorization. Providers cite it as a roadblock to timely patient care and a source of documentation burden, while health insurers say the requirements are necessary to curb unnecessary medical spending.
However, groups representing both sectors now agree on one thing — the government implementing mismatched provisions in rules that intend to standardize data exchange processes is bad for all parties involved.
“We are concerned by the conflicting provisions of [the rules] that would establish two different sets of standards and corresponding workflows to complete [prior authorizations], depending on the type of health plan,” the coalition wrote in its letter to CMS Administrator Chiquita Brooks-LaSure.
The Interoperability and Prior Authorization rule requires federally regulated health plans to offer application programming interfaces to support electronic prior authorizations relying on one data exchange standard, called HL7 FHIR. However, the Administrative Simplifications rule requires a combination of HL7 and another standard called X12, and would apply to all health plans, according to the letter.
“For federally regulated plans, this would require cross walking the two standards for no discernable benefit,” the groups argue.
The conflicting CMS provisions would cause “widespread confusion,” “slow implementation” and be “enormously expensive for both health plans and providers,” the letter says.
Some payers have been walking back prior authorization requirements, including UnitedHealthcare, which said in March it planned to eliminate almost 20% of its prior authorizations starting this summer. The payer also in June rolled back a plan to require prior authorization for colonoscopies and other endoscopic procedures, though it did enact an advance notification process opposed by providers.
Last year, CVS-owned Aetna rolled back prior authorization requirements on cataract surgeries, video EEGs and home infusion for some drugs.
More than a third of physicians say prior authorization requirements are to blame for a serious adverse event for one of their patients, including hospitalization, permanent impairment or death, according to a March AMA survey.
Almost half of the physicians surveyed said prior authorization leads patients to seek urgent or emergency care.