CMS names an e-prescribing standard for prior authorization to expedite access to medications

The Centers for Medicare and Medicaid Services has issued a final rule that, for the first time, is requiring that Part D prescription drug plans support a new electronic prior authorization transaction standard for their Part D e-prescribing programs.

This new electronic prior authorization standard is intended to allow prescribers to see that a drug is subject to prior authorization while they are prescribing it. This is meant to ensure that there are secure electronic transactions between prescribers and Part D plan sponsors, and that patients will not experience delays when picking up their prescriptions. 

CMS will begin enforcing the requirements of this rule on January 1, 2022, although Part D sponsors may choose to implement the new transaction standard earlier. CMS said the action is part of its efforts to strengthen Medicare.

WHAT'S THE IMPACT?

Prior authorization – an administrative process used in healthcare for providers to request approval from payers to provide a medical service, prescription, or supply – takes place before a service is rendered.

The final rule requires that Part D plans adopt the electronic prior authorization standard called the National Council for Prescription Drug Programs SCRIPT standard version 2017071. This ensures secure transmissions and expedites prior authorizations by requiring providers to electronically supply clinical information, such as a patient's diagnosis, before the prescription is sent to the pharmacy. 

Through this new process, beneficiaries can receive their medication faster by decreasing the amount of time it takes to process prior authorizations. The rule also implements the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act requirement for the adoption of the electronic prior authorization standard for the Part D e-prescribing program.

With this new electronic prior authorization standard, prescribers would be able to choose to initiate and manage the process for Part D drug approvals within their electronic prescribing system, improving the process without requiring that patients take additional steps to complete the prior authorization.

THE LARGER TREND

When the rule was still in the proposed rule stage near the beginning of December, it garnered a mixed reaction from the hospital industry. Ashley Thompson, the American Hospital Association's senior vice president of public policy analysis and development, said that hospitals and health systems are appreciative of the efforts to remove barriers to patient care by streamlining the prior authorization process.

"While prior authorization can be a helpful tool for ensuring patients receive appropriate care, the practice is too often used in a manner that leads to dangerous delays in treatment, clinician burnout and more waste in the healthcare system," she said in a statement. "The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care."

Yet the AHA expressed regret on one point in particular.

Thompson said the AHA is disappointed that CMS "chose not to include Medicare Advantage plans, many of which have implemented abusive prior authorization practices, as documented in our recent report. We urge the agency to reconsider and hold Medicare Advantage plans accountable to the same standards."

Days before the new year, the Association for Community Affiliated Plans sent a letter asking CMS to extend the comment period for a proposed rule regarding prior authorization processes and electronic access to health information.

While the organization lauded CMS for its attempts to smooth the flow of health information and reduce provider burden, the group said it's infeasible for its member health plans and staff to perform the requisite evaluation of the rule, while simultaneously dealing with the ongoing COVID-19 pandemic and associated vaccine distribution efforts.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com