Streamlining and Automating Prior Authorization

CMS’s Proposed Rule on Automating Prior Authorization

On 10th December 2020, The Centers for Medicare & Medicaid Services (CMS) proposed a new regulation aimed at improving the sharing of healthcare data between payers and providers and streamlining, a major administrative hassle for providers. This new rule will boost patient data exchange and streamline which will ease the burden on the provider. Additionally, providers can improve patient care by spending more time with their patients. CMS’ proposed rule requires payers in certain government programs to build application programming interfaces (APIs) for data exchange and prior authorization.

This proposed rule addresses a common complaint from providers that have increased in use among plans and takes up too much time away from patients. After implementation of this rule, the provider’s wait time for a decision from a payer on a request will reduce drastically. As per the rule proposal, a maximum 72-hour limit for payers for urgent requests and seven calendar days for non-emergency requests. The rule applies to payers in Medicaid, the Children’s Health Insurance Program, and qualified health plans. CMS is considering including Medicare Advantage plans in a future rule.

As per CMS Administrator Seema Verma, “It is a necessary and important tool for payers to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing administrative costs for the whole system”.

Cause of Provider Burnout

Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout. Completing authorization can be demanding for providers and lead to delays in patient care access, with 46 percent of clinicians submitting authorization requests by fax and 60 percent made over the telephone.

It requires a provider to get approval from a payer for a service, prescription or a medical supply. The provider must submit certain documents to a healthcare payer to receive permission before prescribing the drug. With the pandemic placing an even greater strain on our health care system, the policies in this rule are more vital than ever.

The American Medical Association surveyed 1,000 physicians; key findings of the survey indicate the following:

  • 64% of participating physicians said they wait for at least one business day for insurers to decide on it. Nearly one-third (30%) said they wait at least three business days
  • 92% of participating physicians said the process can lead to delays in access to care, while 78% said that waiting for a decision from insurers causes patients to abandon certain treatments entirely
  • On average, a practice completes 29.1 requests each week; 34% of the surveyed doctors said they have staff members who work solely on the data entry and other steps it.

If passed, this proposed rule would require insurance companies to integrate an FHIR-based API to streamline patient data exchange. In the process, patients would have full access to their medical histories and bring this data from one payer to another. Payers, providers, and patients would gain more access to information, including past and pending decisions, which would reduce administrative burden, cut costs for providers, and boost patient care.

While this proposed rule comes into action you can explore services from an experienced pre-authorization company like Medical Billers and Coders (MBC). Our pre-authorization services help hospitals, outpatient facilities, and physician practices to save their valuable time and minimize the hassles of dealing with different payers. To know more about our billing services contact us at 888-357-3226/