CMS finalized a rule Jan. 17 aiming to streamline the prior authorization process and improve the electronic exchange of health information that it estimates will save $15 billion over 10 years.
The announcement was met favorably by payer and provider groups. Here are eight industry reactions shared with Becker's:
ACHP President and CEO Ceci Connolly: ACHP applauds the Centers for Medicare and Medicaid Services (CMS) for finalizing the Interoperability and Prior Authorization Rule, which takes steps in the right direction to ensure patients have timely access to needed care, prioritizing provider engagement and patient satisfaction. ACHP represents nonprofit community health plans with strong payer-provider alignment. Our member plans work proactively with clinicians to identify the right care pathway up front. Electronic prior authorization will accelerate and improve the use of tools to ensure patients are getting the right care, at the right time. ACHP appreciates that CMS has created consistent standards across federal programs to streamline this important process for consumers and supports CMS providing the necessary implementation time to operationalize the final rule.
AHIP: It's crucial that we all work towards ensuring patients have access to the information they need to make informed healthcare decisions. CMS took a step in the right direction by finalizing the Interoperability and Prior Authorization rule. Health insurers have been diligently working to build the infrastructure to expand data sharing with patients, providers and other payers. With this rule CMS creates a road map for public and private payers in federal programs to work in tandem with providers to put this preparatory work into practice to improve patient access, outcomes, affordability and experience.
Electronic prior authorization is one such avenue that can help us maintain the necessary checks to ensure patients receive safe and evidence-based care while reducing decision times to get patients to care faster and administrative burdens on providers and plans. For patients and providers in the MA program, the new rules are on top of additional process and transparency improvements and other requirements that CMS has implemented for prior authorization.
We appreciate CMS' announcement of enforcement discretion that will permit plans to use one standard, rather than mixing and matching, to reduce costs and speed implementation. However, we must remember that the CMS rule is only half the picture; the Office of the Coordinator for Health Information Technology should swiftly require vendors to build electronic prior authorization capabilities into the electronic health record so that providers can do their part, or plans will build a bridge to nowhere.
We cannot afford to delay any further when it comes to implementing electronic prior authorization capabilities. Let's work together to ensure that we can provide patients with the best possible healthcare experience while reducing administrative burdens on providers and plans.
American Hospital Association President and CEO Rick Pollack: The AHA commends CMS for removing barriers to patient care by streamlining the prior authorization process. Hospitals and health systems especially appreciate the agency’s plan to require Medicare Advantage plans to adhere to the rule, create interoperable prior authorization standards to help alleviate significant burdens for patients and providers, and to require more transparency and timeliness from payers on their prior authorization decisions.
With this final rule, CMS addresses a practice that too often has been used in a manner that leads to dangerous delays in patient treatment and clinician burnout in the healthcare system. The AHA is grateful to CMS for its efforts to improve patient access to care and help clinicians focus on patient care rather than paperwork.
American Medical Association President Jesse Ehrenfeld, MD: The American Medical Association applauds CMS Administrator [Chiquita] Brooks-LaSure for heeding patients and the physician community in a final rule that makes important reforms in government-regulated health plans' prior authorization programs for medical services.
Today’s final rule requires impacted plans to support an electronic prior authorization process that is embedded within physicians' electronic health records, bringing much-needed automation and efficiency to the current time-consuming, manual workflow. The AMA also appreciates that the rule will significantly enhance transparency around prior authorization by requiring specific denial reasons and public reporting of program metrics as well as requiring that prior authorization information be available to patients to help them become more informed decision-makers.
The AMA commends the Biden administration for its prior authorization reforms that prioritize patients' access to care and reducing administrative burdens for physicians and their staff. The AMA looks forward to continuing to work with CMS on this critical issue, including expanding these improvements to drug prior authorization. Through our Recovery Plan for America’s Physicians, the AMA is working on every front to tackle prior authorization challenges so physicians can focus on patients rather than insurance obstacles to medically necessary care.
Better Medicare Alliance President and CEO Mary Beth Donahue: The Better Medicare Alliance applauds CMS for its leadership in modernizing the prior authorization process and ensuring interoperability works for everyone. We believe these changes serve our shared goals of protecting prior authorization's essential function in coordinating high-value care while also ensuring beneficiaries continue to receive the care they need when they need it. We are particularly encouraged by the rule's data exchange provisions, which will further improve communication between health plans, providers, and beneficiaries. We thank CMS for listening to feedback from Medicare Advantage stakeholders during the rulemaking process.
Blue Cross Blue Shield Association: Our priority is simple: ensure everyone gets the care they need when they need it. While we are still reviewing the rule and are open to future discussions, Blue Cross and Blue Shield companies are actively working with patients and clinicians to ensure safety, quality and value for their members. Prior authorization is an important tool to prevent fraud and direct beneficiaries to high-value, medically appropriate care. It also helps ensure that patients receive care from the best providers and the most-appropriate sites of care. However, we know that it can be improved, and we will continue to work with providers and lawmakers to streamline the process, increase transparency, reduce administrative burdens and ensure timely access to clinically appropriate, affordable healthcare.
Implementation of the final rule will take time and we urge policymakers to not take additional actions while it's being worked through.
Federation of American Hospitals President and CEO Chip Kahn: Patients need protection from arbitrary critical care denials and delays due to insurance company prior authorization abuse. It is important that CMS is taking a vital step to ensuring this protection by setting guiderails for prior authorization that should rein-in the worst abuses. We urge Congress to further attack prior authorization abuse and protect access to care by passing the bipartisan Ensuring Seniors’ Timely Access to Care Act.
Medical Group Management Association Senior Vice President of Government Affairs Anders Gilberg: With prior authorization continuously ranking as the most burdensome regulatory issue facing medical groups, MGMA supports today’s action by CMS to finalize its proposals to streamline and standardize the process. The increased transparency provisions — requiring health plans to provide clarity on the reasoning behind care denials and to publicly report aggregated metrics about their prior authorization programs annually — will help shine a light on the egregious abuse of prior authorization by payers under the guise of looking out for patients’ best interests. This final rule is an important step forward towards MGMA’s goal of reducing the overall volume of prior authorization requests — only then will medical groups find meaningful reprieve from these onerous, ill-intentioned administrative requirements that dangerously impede patient care.