Healthcare and technology groups support proposed interoperability and prior authorization rule

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Healthcare and technology groups want Medicare Advantage plans included in the Centers for Medicare and Medicaid Services' proposed rule to expand access to health information and improve the prior authorization process.

MGMA, the Medical Group Management Association and WEDI, the Workgroup for Electronic Data Interchange, both said they favor the inclusion of Medicare Advantage plans in the final rule. WEDI would also like CMS to identify opportunities to incentivize commercial payers to support rule requirements.

CMS proposes that plans be required to provide specific reasons for prior authorization denials. Both MGMA and WEDI agree plans need a deadline to make prior authorization decisions, but differ on that timeline.

WEDI agrees with the current CMS proposed timeframe of seven days for non-urgent requests and 72 hours for expedited requests, while MGMA wants to see that shortened to 48 hours for standard prior authorizations and 24 hours for expedited prior authorizations. 

CMS said its proposed standard is twice as fast as the existing Medicare Advantage response time limit.

The current time frame will do little to mitigate the current challenges involved with processing prior authorization requests in a timely manner so as to not delay care, MGMA said. MGMA urges CMS to clarify in the final rule that these required time frames refer to final decisions and to develop an enforcement plan that does not entirely rely on medical groups to ensure plan compliance, it said.

MGMA and WEDI also want these provisions implemented before the current proposed date of January 1, 2026. CMS should make these requirements effective immediately upon finalization of this rule, MGMA said. WEDI recommends CMS give the industry 36 months following the effective date of the final rule to comply with the requirements.

CMS released the proposed rule in December. One reason for implementing the changes is physician and clinician burnout, said Surgeon General Vice Admiral Vivek Murthy, during a press call in January.

Comments were due by Monday, March 13.

WHY THIS MATTERS: REACTION

"Automating prior authorization is only one part of achieving meaningful reform," said MGMA, in comments to CMS on the interoperability and prior authorization proposed rule. "Much work remains to be done, including efforts to provide greater transparency, reduce the overall volume of prior authorization requests and improve peer-to-peer reviews."

MGMA supports gold-carding initiatives, and while gold-carding programs have the potential to reduce burden and delays in care, only 7% of practices report that MA plans have a gold-carding program available.

In gold-carding, physicians who have a 90% prior authorization approval rate over a six-month period on certain services will be exempt – or "gold carded" – from prior authorization requirements for those services, according to the American Medical Association.

MGMA does not want to link electronic prior authorization requirements to CMS' Quality Payment Program. To link prior authorization to the Promoting Interoperability component of Merit-based Incentive Payment System would only exacerbate unnecessary burden and work against CMS' goal of reducing physician burden, medical staff time, and prior authorization-related costs, it said.

INTEROPERABILITY

The rule proposes to require certain payers to implement standards that would enable data exchange from one payer to another when a patient changes payers or has concurrent coverage.
 
WEDI said it strongly supports the appropriate use of application program interface (API) technology to promote interoperability and improve prior authorization processes. WEDI recommends a response time of two business days for both the Payer-to-Payer and Patient Access APIs.

''We urge CMS to closely monitor the industry following the implementation date to determine if these response times should be modified," WEDI said. WEDI urges CMS to align the prior authorization proposals with the proposal to establish a national standard for electronic attachments and the expected expansion of the Office of the National Coordinator for Health Information Technology certification program.

THE LARGER TREND

An AMA survey shows that 94% of physicians report care delays due to prior authorization, 80% report it can lead to treatment abandonment and 33% report it can lead to serious adverse events for patients.

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

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

Wendy Paul and Kyle Longhurst will offer more detail in their HIMSS23 session "Using Machine Learning to Reduce Discharge Medication Errors." It is scheduled for Thursday, April 20, at 2:30 p.m. - 3:30 p.m. CT at the South Building, Level 4, in room S401.