Current prior authorization practices are adding to burnout, surgeon general says

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The Centers for Medicare and Medicaid Services outlined changes that will be made to speed up and align the prior authorization process across all payers, during a press call on Tuesday.

CMS released the proposed rule on expanding access to health information and improving the prior authorization process on December 6. One reason for implementing the changes is physician and clinician burnout, said Surgeon General Vice Admiral Vivek Murthy.

Current prior authorization, with its requirements to fax information and signatures, causes delays, and sometimes results in patients abandoning care, he said. Institutions have to hire people full time just to work on prior authorization, Murthy said. It is increasing clinician burden and driving burnout.

"This is a crisis for all of us," he said.

The proposed rule would require certain payers to implement an electronic prior authorization process for attachments and signatures. It would require implementation of a Health Level 7 (HL7) Fast Healthcare Interoperability Resources FHIR standard Application Programming Interface (API) to support electronic prior authorization.

Certain payers would be required to implement standards enabling data exchange from one payer to another payer when a patient changes or has concurrent insurance coverage, which is to help ensure that complete patient records are available throughout the transition, CMS said.

Secondly, the proposed rule would require insurers to provide reasons for the denial.

The third change would align prior authorization policy across Medicare, Medicare Advantage, Medicaid, CHIP and Affordable Care Act marketplace plans, according to CMS Administrator Chiquita Brooks-LaSure.

Much of the feedback CMS is hearing is around Medicare Advantage and also enrollees changing from one form of coverage to another, she said. People are cycling through MA, Medicare and dually eligible plans, Brooks-LaSure said. The proposed rule would ensure that MA enrollees receive the same care as those in traditional Medicare, she said.

"These rules are making sure they're aligned across payers," she said. "This is something we hear time and time again."

Much of the feedback from providers is gratitude for addressing the issue, Brooks-LaSure said.

"What I took away is how much prior authorization is weighing down providers, interfering with their own wellbeing and ability to deliver care," she said, adding that getting prior authorization is clinically appropriate.

Comments on the proposed rule are due on March 13. 

WHY THIS MATTERS

CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals over $15 billion over a 10-year period.

THE LARGER TREND

The Advancing Interoperability and Improving Prior Authorization Proposed Rule 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.

The rule 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 issuers on the federally-facilitated exchanges, promoting alignment across coverage types.

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