Provider Groups Say Final Rule Will Relieve Prior Authorization Burdens

January 19, 2024 - Provider groups are commending CMS for finalizing patient data-sharing policies and prior authorization requirements.

The CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage, Medicaid, and Children’s Health Insurance Program plans to provide prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests starting in 2026. Payers must provide a specific reason for prior authorization request denials.

Additionally, the rule requires payers to implement a Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Prior Authorization application programming interface (API) to facilitate electronic prior authorization processes.

Impacted payers must add prior authorization information to their Patient Access APIs and implement Provider Access, Payer-to-Payer, and Prior Authorization APIs to improve data-sharing between different entities.

The major provider organizations recognized the rule as an important first step to reducing prior authorization burdens, but some urged CMS to expand the requirements.

“With prior authorization continuously ranking as the most burdensome regulatory issue facing medical groups, MGMA supports today’s action by CMS to finalize its proposals to streamline and standardize the process,” Anders Gilberg, senior vice president of Government Affairs at the Medical Group Management Association (MGMA), said in a statement.

“The increased transparency provisions — requiring health plans to provide clarity on the reasoning behind care denials and to publicly report aggregated metrics about their prior authorization programs annually — will help shine a light on the egregious abuse of prior authorization by payers under the guise of looking out for patients’ best interests.”

The American Medical Association (AMA) praised the rule’s policies that will increase the use of electronic prior authorization processes.

“Today’s final rule requires impacted plans to support an electronic prior authorization process that is embedded within physicians’ electronic health records, bringing much-needed automation and efficiency to the current time-consuming, manual workflow,” Jesse M Ehrenfeld, MD, MPH, president of AMA, shared in a statement.

The American Medical Group Association (AMGA) expressed similar sentiments but called on CMS to take further action.

“Today’s rule does not apply to commercial insurance plans. AMGA strongly recommends Congress build on CMS’ example and apply the data-sharing requirements across the health insurance sector,” the group wrote in a press release. “By requiring all payers to share claims data with providers, every patient will benefit from providers who are as informed as possible about past health conditions, current treatments, and, crucially, any gaps in care.”

AMGA also stressed that the decision timelines should be shorter.

“There is nothing expedited about three days. Slow-moving prior authorization decisions leave patients in limbo and create a cascading effect of backlogs in the system,” Jerry Penso, MD, MBA, president and CEO of AMGA, said.

In a press release emailed to RevCycleIntelligence, the American College of Rheumatology (ACR) raised concerns about the electronic prior authorization measure for providers participating in the Merit-based Incentive Payment System (MIPS). The group said that the measure would create an additional burden for physicians.

Hospital groups, including the American Hospital Association (AHA), voiced their appreciation for the final rule as well.

“The AHA commends CMS for removing barriers to patient care by streamlining the prior authorization process. Hospitals and health systems especially appreciate the agency’s plan to require Medicare Advantage plans to adhere to the rule, create interoperable prior authorization standards to help alleviate significant burdens for patients and providers, and to require more transparency and timeliness from payers on their prior authorization decisions,” Rick Pollack, president and CEO of AHA, said in a statement.

“With this final rule, CMS addresses a practice that too often has been used in a manner that leads to dangerous delays in patient treatment and clinician burnout in the health care system. AHA is grateful to CMS for its efforts to improve patient access to care and help clinicians focus on patient care rather than paperwork.”