In July, the AMA responded to he Centers for Medicare & Medicaid Services (CMS)’ Request for Information to Determine Industry Interest and Capabilities for Modernizing and Improving Access to Medicare Fee-for-Service Requirements, supporting thecenter’s initiative overall, but expressing concern that it might signal the agency’s intent to increase the use of pre-authorization in original Medicare fee-for-service plans, negatively affecting patients and physicians.
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November 2023In December 2022, CMS issued a proposed rule to expand consumer access to health information and improve the prior authorization process for medical items and services. In the proposed rule, CMS requires some payers to use an electronic prior authorization process, to shorten the time frames to respond to prior authorization requests, and to make prior authorization process more transparent, requiring specific reasons when denying requests. In addition, payers must publicly report certain prior authorization metrics and send decisions within 72 hours for expedited requests and seven calendar days for requests. CMS is also requiring data standards to allow data to be exchanged between payers when a patient changes insurance coverage or has concurrent coverage.
The deadline to submit comments was March 13, 2023; as of September, CMS was evaluating the public response for inclusion in a final rule. (You can read the rule in the Federal Register at https://www.federalregister.gov/documents/2022/12/13/2022-26479/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability.)
The Benefits of Electronic Approval Platforms
While electronic platforms can help in many cases, there can be challenges. For example, information submitted can become lost in a way that wouldn’t have happened in a bygone era when medical practices called up their designated insurance contact to get approval for a procedure. Because of computer glitches, a physician practice staff member might think the process of approval has begun when it actually hasn’t. This can cause delays in treatment. “Information is sometimes sent into a black hole,” Hargrove said.
Lisa described a kind of give-and-take to the changes that have happened in the prior authorization process over the years. Although the review process for more complicated approval requests may be more cumbersome than it used to be, the quick approval of simpler cases allows more time to deal with these complications.
“If we’re on hold waiting for approval for one patient for 45 minutes to an hour, we still have all the other patients who we need to get through our system,” she said. “So, using computer platforms definitely helps us with productivity within the offices as well and getting those authorizations a little bit quicker.”