CMS providers pay to enact pre-licensing fixes

Photo: Emir Memidovsky/Getty Images

Chiquita Brooks-LaSure, in charge of the Centers for Medicare and Medicaid Services, and U.S. Deputy Surgeon General Admiral Vivek H. Murthy recently held an in-person roundtable discussion on prior authorization reform in federally sponsored health care programs, as providers pressed CMS for Complete reforms to reduce administrative burdens.

The Biden administration said it looks forward to addressing documented violations in the advance authorization program and ensuring patients have timely access to needed medical care.

Many of the presenter attendees belong to the Specialty Medicine Alliance, and they echoed the call for the federal government to codify and finalize pre-licensing reforms.

“Prior authorization is an impediment to care that deeply harms patients,” said Dr. Eugene Y. “AUA commends CMS for the opportunity to engage in today’s dialogue about how to remove that barrier so patients can get the care they need when they need it. Constant communication is key to ensuring CMS understands and addresses the challenges that clinicians and their patients face every day.”

Dr. Shivan Mehta, a gastroenterologist who attended the meeting for the alliance, said, “We know that health disparities exist in many GI conditions and diseases, and prior authorization only exacerbates this problem. The solutions offered by HHS will make a difference in ensuring that patients get the care they need when they need it.”

What is the effect

The Alliance has long been a proponent of prior licensing reform. The group said the program had turned into a “stressful process” that required doctors to obtain pre-approval for medical treatments or tests before providing care to their patients.

The coalition said the approval process is lengthy and typically requires doctors or their staff to spend the equivalent of two days or more each week negotiating with insurance companies — time that would be better spent caring for patients. She added that patients face significant barriers to necessary medical care due to pre-authorization requirements for items and services that are eventually routinely approved.

The alliance recently released a survey of physician members about prior authorization and other utilization review practices. Respondents overwhelmingly indicated that advance authorization use has increased in the past five years across all categories of services and treatments.

According to the survey, more than 93% of the respondents answered that the PA has increased in relation to the procedures. More than 83% responded that PA was increased in diagnostic tools, such as lab and primary imaging; 92% reported that PA had a negative effect on patients. And 66% said PA had increased for prescription drugs, and doctors noted that even many generic drugs now require pre-approvals.

The biggest trend

At a press conference on January 17, the same day as the roundtable, Brooks-LaSure and Murthy outlined changes that would be made to speed up the pre-authorization process and align it across all payers. Murthy described prior authorization as a burden that added to the doctor’s fatigue.

The rule proposed by CMS would require certain payers to go through a pre-authorization process for attachments and signatures. Health Level 7 (HL7) implementation may require standard FHIR API to support electronic pre-authorisation.

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

The proposed rule also requires insurance companies to provide reasons for refusal. The third change would align prior authorization policy across Medicare, Medicare Advantage, Medicaid, CHIP and Affordable Care Act market plans, according to Brooks-LaSure.

The rule will generally apply to Medicare Advantage organizations, state Medicaid and CHIP agencies, Medicaid managed care plans, CHIP-administered care entities, and qualified health care plan issuers on federally facilitated exchanges, promoting compatibility across types of coverage.

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