Payers and providers came out in support of a new rule from the CMS proposing requirements on certain health insurers in a bid to improve the prior authorization process, though provider groups say there’s more to be done to codify measures into law for Medicare Advantage plans.
Previous regulation from the Trump administration targeting prior authorization, a process in which a physician must get the green light from an insurer for medication or treatment before administering it, was heavily criticized by both health insurers and hospitals.
But the rule released Tuesday is getting a warmer initial welcome from the healthcare sector.
“We applaud CMS for putting patients first with a proposed rule that allows them to easily to share their data with entities of their choosing,” said Matt Eyles, president and CEO of insurance lobby AHIP, in a statement.
AHIP said it was especially pleased that physicians and hospitals will be incentivized to adopt electronic prior authorization processes to meet certain quality measures in Medicare, but that the CMS needs to do more to protect health data shared with entities that aren’t required to comply with HIPAA.
“While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization’s essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community’s work streamlining this clinical tool to better serve its 30 million diverse enrollees,” said Mary Beth Donahue, CEO of the Better Medicare Alliance, which represents MA plans.
Donahue said the rule’s data exchange provisions requiring payers to build and maintain application programming interfaces to more easily share data with providers, patients and each other, are also welcome.
Creating those APIs was a sticking point for health insurers with the original rule, which had a tighter compliance timeline of two years than the one proposed by the CMS this week, which will kick into gear in four years.
Meanwhile, providers cheered regulatory plans for Medicare Advantage in the new rule. The original 2020 rule excluded popular MA plans from the prior authorization requirements.
The American Hospital Association said in a statement it “commends” CMS for streamlining the prior authorization process, and that “hospitals and health systems especially appreciate that CMS included Medicare Advantage plans.”
In April, the HHS Office of the Inspector General released a report finding that some MA plans routinely denied prior authorization requests, even though they met Medicare coverage rules. A 2018 audit by the OIG found MA plans ultimately approved 75% of requests that were originally denied following appeal.
The AHA and multiple other provider groups — including the Regulatory Relief Coalition, a group of physician specialty organizations advocating for fewer regulatory hurdles — urged Congress to pass bipartisan legislation that would impose more stringent prior authorization requirements on MA plans.
That legislation, dubbed the Improving Seniors Timely Access to Care Act, passed the House unanimously in September, but has yet to pass the Senate.
If adopted, the legislation would require MA plans to address prior authorization requests more quickly, standardize the documentation process and create a real-time process for certain items and services that are routinely approved.
The onus is rising on legislators and policymakers to address prior authorization, which is a common sticking point between payers and providers. Health insurers say the process is necessary to curb unnecessary or wasteful healthcare spending, while doctors argue it delays healthcare services while contributing to burnout.
According to a recent AHA study, 95% of hospitals say staff are spending more time seeking prior authorization approval. Meanwhile, prior authorization is a commonly cited source of administrative burden for healthcare providers.
Some states have recently taken steps to ameliorate prior authorization requirements.
In Pennsylvania, Gov. Tom Wolf in November signed a law requiring commercial health insurance carriers and Medicaid plans to provide a more streamlined approval process for non-urgent and emergency services. And in Texas, provisions of its “Texas gold card bill” came into effect in October, exempting physicians with a 90% prior authorization approval rate for certain services from prior authorization requirements.