The response from provider organizations has been largely positive to a new Centers for Medicare & Medicaid Services (CMS) proposed rule that would require certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies that CMS said would make the prior authorization process more efficient and transparent.
CMS said the rule also proposes to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers. The requirements would begin Jan. 1, 2026.
“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” said CMS Administrator Chiquita Brooks-LaSure, in a statement. “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.”
The proposed rule would address challenges with the prior authorization process faced by providers and patients. Proposals include requiring implementation of a FHIR standard application programming interface (API) to support electronic prior authorization. They also include requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests, which is twice as fast as the existing Medicare Advantage response time limit.
The proposed rule would add a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.
The proposed rule drew praise from provider groups for moving in the right direction.
Medical Group Management Association’s Anders Gilberg, senior vice president of government affairs, issued a statement applauding the proposed rule. “MGMA is encouraged to see that CMS heeded our call to include Medicare Advantage plans in the scope of this proposed rule,” Gilberg said. “An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals. The onerous methods of completing these requests, coupled with the increasing volume is unsustainable. An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care. This is a positive step forward for both medical groups and the patients they treat. We look forward to working with CMS to refine and finalize this rule.”
Ashley Thompson, the American Hospital Association’s senior vice president of public policy analysis and development, issued a statement saying, “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. Hospitals and health systems especially appreciate that CMS included Medicare Advantage plans in these requirements, as the AHA has urged. Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens health care providers and adds unnecessary costs to the healthcare system. The AHA looks forward to carefully reviewing the proposed rule, and we continue to urge the Senate to pass the Improving Seniors’ Timely Access to Care Act to codify these protections in law.”
In a blog post, Premier’s senior vice president of government affairs, Soumi Saha, said Premier is pleased that CMS proposes transparency requirements that will increase plan accountability for rampant prior authorization delays and denials. “Premier will be evaluating the proposed new interoperability measures imposed on providers with an eye to ensuring that they are not creating new burden while attempting to alleviate the existing burden. Premier is also disappointed that the proposed rule lacks a recognition that innovative technology already exists to allow for real-time decisions from payers — CMS must be bolder in incentivizing payers to move to real-time responses.”
CMS said proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.
These proposed requirements would generally apply to Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs), promoting alignment across coverage types. CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals over $15 billion over a 10-year period.
Finally, the proposed rule includes five requests for information related to standards for social risk factor data, the electronic exchange of behavioral health information among behavioral health providers, improving the exchange of medical documentation between certain providers in the Medicare Fee-for-Service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interoperability can play in improving maternal health outcomes.
The proposed rule replaces the previous proposed rule, published in December 2020, and addresses public comments received on that proposed rule.
