AHA, others push CMS to revise prior authorization reform requirements

Photo: Emir Memedovski/Getty Images

Industry groups including the American Hospital Association, American Medical Association and the Blue Cross Blue Shield Association have sent a joint letter to the Centers for Medicare and Medicaid Services requesting that the government agency reconsider regulatory proposals requiring different electronic standards for data exchange during the prior authorization process.

Along with incentives for providers to adopt electronic prior authorization, CMS' proposed rule, issued late last year, will require payers and states to smooth out their prior authorization processes and improve electronic data exchange by 2026. A Fast Healthcare Interoperability Resources (FHIR) application programming interface (API) will handle the prior authorization.

The groups said that, while they appreciate the administration's efforts to reduce administrative burdens and costs within the healthcare system, including prior authorization reform, they described the regulatory proposals as "conflicting." They say they potentially set the stage for multiple prior authorization electronic standards and workflows – which would contribute to the "costly burdens that administrative simplification seeks to alleviate."

WHAT'S THE IMPACT?

Although the electronic standards proposed in the rule align with those recommended by the National Committee on Vital and Health Statistics in 2016, the groups said there have been significant developments in both the technology and regulatory spaces in the intervening years.

First, they said, major efforts are underway to automate PA-related data exchange leveraging Health Level 7 (HL7) FHIR implementation guides. But more importantly, according to the groups, the Advancing Interoperability and Improving Prior Authorization proposed rule would require federally regulated health plans to offer HL7 FHIR-based application programming interfaces to support electronic PA information exchange.

By contrast, the attachments rule would require a combination of both electronic data interchange standard X12 and HL7 standards and apply to all health plans under the HIPAA regulatory pathway.

The groups said they were concerned that the provisions would establish two different sets of standards and corresponding workflows to complete the PA process, depending on the type of health plan. For federally regulated plans, they said this would require "cross-walking" the two standards for no discernable benefit.

"This outcome," they said, "would directly counter the foundational principles of the original HIPAA administrative simplification statute and regulations (i.e., adoption of electronic standards to support uniform communication between providers and all health plans); cause widespread industry confusion; and be enormously expensive for both health plans and providers, as they would undoubtedly need to implement technologies to meet the requirements of both" proposed rules.

For those reasons, the organizations advised against adoption of standards for PA attachments as proposed in the rule.

THE LARGER TREND

The proposed rule, issued in December 2022, would require implementation of an HL7 FHIR standard API to support electronic prior authorization. Certain payers would need to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours to seven days, depending on the level of urgency, which is twice as fast as the existing Medicare Advantage response time limit, CMS said.

The proposed rule would add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.

The rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.

In March, the AMA released a survey showing that 94% of physicians report delays in care associated with prior authorization. 

Physicians spend almost two business days each week on prior authorization requests and 35% have had to hire additional staff to exclusively handle the administrative burden, the AMA said.

The AMA said other survey results show that 80% of physicians report that prior authorization can at least sometimes lead to treatment abandonment; 33% of physicians report prior authorization leading to a serious adverse event for a patient in their care – with 9% reporting it's led to permanent bodily damage, disability or death.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com