Health insurance prior authorization rules proposed by CMS

The Centers for Medicare and Medicaid Services aims to overhaul health insurance prior authorizations under a proposed rule published Tuesday.

The regulation would require Medicare Advantage, Medicaid and health insurance exchange carriers to ease their prior authorization processes and respond to “urgent” requests within 72 hours and standard requests within seven days. This would halve the amount of time Medicare Advantage plans currently have to respond to clinicians’ prior authorization requests, according to CMS.

Insurers would have to justify denials and publicly report data on their prior authorization decisions. Insurers and providers could also be required to implement technology that would allow patient health information to flow from one payer to another so that medical records would be available when policyholders change insurance companies.

“The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote healthcare data sharing to improve the care experience across providers, patients and caregivers—helping us to address avoidable delays in patient care and achieve better health outcomes for all ,” CMS Administrator Chiquita Brooks-LaSure said in a news release.

CMS estimates the proposed rule would save providers more than $15 billion over 10 years.

“The AHA commends CMS for taking important steps to remove inappropriate barriers to patient care by streamlining the prior authorization process for some health insurance plans,” Ashley Thompson, the American Hospital Association’s senior vice president for public policy analysis and development, said in a news release. release. “Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens healthcare providers and adds unnecessary costs to the healthcare system.”

The rule would add interoperability measures to the quality metrics on which providers are rated under the Merit-based Incentive Payment System and hospital quality programs.

“Americans should have clear, concise and customized information with streamlined processes that improve healthcare quality, affordability and accessibility. Health insurance providers are committed to delivering for them, and we look forward to continued partnership with the administration on these important issues,” Matt Eyles , CEO of the health insurance trade group AHIP, said in a news release.

The House passed the Improving Seniors’ Timely Access to Care Act in September, which would require Medicare Advantage carriers to adopt similar standards. Advocates hope the bipartisan bill—which is supported by health insurance and provider groups—will advance through the Senate during the post-election lame-duck session this month.

“We are pleased by HHS’ proposed rule to streamline prior authorization processes, but comprehensive reform is needed to reduce the volume of prior authorizations and ensure patients’ timely access to care,” American Academy of Family Physicians President Dr. Tochi Iroku-Malize said in a news release. “The rule is good news for family physicians and an important first step in alleviating burden and improving access to care. We continue to urge the Senate to swiftly pass the Improving Seniors’ Timely Access to Care Act.”

The proposed rule is scheduled to be formally published in the Federal Register on Dec. 13.

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