The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve the electronic exchange of healthcare data among payers, providers, and patients, and streamline processes related to prior authorization. CMS says by increasing data flow and reducing burden, the proposed rule would give providers more time to focus on their patients and provide better care. The comment period on the proposed rule will close on January 4, 2021.
“Prior authorization 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,” said CMS Administrator Seema Verma.
The rule would require payers in Medicaid, the Children’s Health Insurance Program (CHIP), and Qualified Health Plan (QHP) programs to build application programming interfaces (APIs) to support data exchange and prior authorization. APIs allow two systems, or a payer’s system and a third-party app, to communicate and share data electronically.
CMS says the APIs could allow providers to know in advance what documentation would be needed for each health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s electronic health record or other practice management system. Medicare Advantage plans are not included in the proposal, but CMS said it is considering whether to do so in future rulemaking.
The proposed rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers—the rule proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the federally-facilitated exchanges, to issue decisions on urgent requests and seven calendar days for non-urgent requests. Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing.
CMS said the policies could lead to fewer prior authorization denials and appeals, while improving communication and understanding between payers, providers, and patients.