CMS releases Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule

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In a newly proposed rule, the Centers for Medicare and Medicaid Services is changing prior authorization standards to speed up the time it takes for payers to approve the requests and is implementing HL7 FHIR standards to support an electronic process.

CMS is proposing to require certain payers, including Medicare Advantage organizations, to implement electronic prior authorization and to send decisions within 72 hours for expedited requests and seven days for non-urgent requests.

The Advancing Interoperability and Improving Prior Authorization Proposed Rule, released Tuesday, would require implementation of a Health Level 7 (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.

These proposed requirements would generally apply to Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-Facilitated Exchanges (FFEs), promoting alignment across coverage types. CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals more than $15 billion over a 10-year period.

Proposed policies in the rule include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients' data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.

Finally, the proposed rule includes five requests for information related to standards for social risk factor data, the electronic exchange of behavioral health information among behavioral health providers, improving the exchange of medical documentation between certain providers in the Medicare fee-for-service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interoperability can play in improving maternal health outcomes.

WHY THIS MATTERS

The proposed rule is aligned with CMS' ongoing work to strengthen patient access to care, reduce administrative burden for clinicians so they can focus on direct care and support interoperability across the healthcare landscape, CMS said. It withdraws and replaces the previous proposed rule on interoperability and prior authorization, published in December 2020.

The proposed rule has received support from numerous hospital and physician groups – who voiced particular approval that the proposal includes Medicare Advantage plans – and from the insurance association, AHIP.

The deadline to submit comments is March 13, 2023. 

Matt Eyles, president and CEO of AHIP, said, "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. AHIP's Fast PATH demonstration showed that electronic processes for prior authorization are essential for ensuring that patients receive swift, evidence-based care that improves value and reduces administrative burdens for everyone."

However, Eyles said there is a gap in the nation's privacy framework for personal health information shared with entities that are not required to comply with HIPAA.

"We strongly recommend that CMS work with Congress to address this gap," Eyles said.

Premier also cited the need for closure of gaps that it said exists in the proposed rule around payer transparency of prior authorization denials and approvals through the use of advanced technologies. The healthcare company said it would continue to work with Congress to advance provisions in the bipartisan Improving Seniors' Timely Access to Care Act to close these gaps.

The American Hospital Association said it would continue to urge the Senate to pass the Improving Seniors' Timely Access to Care Act to codify protections in law.

Ashley Thompson, senior vice president, public policy analysis and development for the AHA said, "The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans. Hospitals and health systems especially appreciate that CMS included Medicare Advantage plans in these requirements, as the AHA has urged. Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens health care providers and adds unnecessary costs to the health care system."
 
Medical Group Management Association (MGMA) Senior Vice President of Government Affairs Anders Gilberg said, "MGMA Medical Group Management Association is encouraged to see that CMS heeded our call to include Medicare Advantage plans in the scope of this proposed rule. An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals. The onerous methods of completing these requests, coupled with the increasing volume is unsustainable. An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care."

The American Academy of Family Physicians President Dr. Tochi Iroku-Malize said, "The average physician spends too much time completing prior authorizations – taking time away from patients and potentially creating dangerous care delays."

AAFP also urged the Senate to swiftly pass the Improving Seniors' Timely Access to Care Act to protect Medicare Advantage beneficiaries from what the organization called unnecessary care delays and to alleviate physician burden.

Better Medicare Alliance said, "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, president and CEO of the BMA. "Notably, the proposed rule addresses recent concerns from some lawmakers related to the budgetary impact of the BMA-endorsed Improving Seniors' Timely Access to Care Act, legislation that already passed the U.S. House of Representatives with unanimous support."
  
THE LARGER TREND

CMS has been building upon its Interoperability and Patient Access final rule released in March 2020.

In December 2020, CMS released a proposed interoperability rule to streamline prior authorizations and to improve the electronic exchange of data. The Office of the National Coordinator for Health IT proposed to adopt certain standards through an HHS rider on the CMS proposed rule. 

At the time, the proposed rule did not include Medicare Advantage plans, to the disappointment of provider groups such as the AHA.

ON THE RECORD

"CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care," CMS Administrator Chiquita Brooks-LaSure said. "The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers – helping us to address avoidable delays in patient care and achieve better health outcomes for all."

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org