In the United States, prior authorization (“PA”) is a cost-containment tool utilized by payers to reduce payment for medically unnecessary or inappropriate patient care. Despite its laudable policy goals, the use of PA faces increasing scrutiny for creating administrative burdens on providers and delays in patient care. Providers report that the regulatory burdens of PA exceed those for claim audits, appeals, compliance with the No Surprises Act, and COVID-19 Provider Relief Fund reporting.
While reforms proposed by the Biden Administration have helped tackle some problematic payer PA practices that prevent timely access to needed care, more needs to be done to reduce the administrative burden on providers and improve the patient experience.
On April 5, 2023, the Centers for Medicare & Medicaid Services (“CMS”) issued its 2024 MA and Part D final rule1, applicable to coverage beginning January 1, 2024, finalizing regulatory changes that aim to streamline PA processes:
While these changes are encouraging for provider organizations who have long advocated for PA reform, R1 recognizes that further rulemaking and Agency action is needed to streamline the PA approval process, establish determination timeframes, and ensure that plans are held accountable for following new requirements.
CMS Proposes Shortened Timeframes Yet Fails to Address Payer Shortcomings
On December 13, 2022, CMS released a proposed rule2 that will require MA plans and other impacted payers to streamline PA processes and improve the electronic exchange of health data by 20263. If finalized, the rule would mandate payers to facilitate the electronic exchange of PA requests and determinations and provide shorter timeframes for payers to make and provide notice of PA decisions. While CMS’ proposal would help ease the long wait times for PA determinations and reduce administrative burden on providers, there are gaps in the proposed rule that CMS did not address, such as transparency of retrospective PA denials by payers and establishing mechanisms to hold payers accountable for noncompliance.
R1 provided a formal response to CMS’ proposed rule (summarized below) identifying opportunities to improve the regulatory framework, designed to preserve the agency’s policy goals while minimizing negative impacts to patients and providers.
The R1 Regulatory Team provides a wealth of CMS news and information. Read on for more expert information.
The Future of PA for Providers
While the new requirements proposed by the current Administration are a good start, providers should continue to advocate for further PA reform. Enhancements would not only improve the patient experience and treatment outcomes but decrease the time and unnecessary administrative burden providers currently face.
R1 understands the increasingly complex regulatory environment and the related challenges our customers experience navigating these issues and strives to advocate for providers by submitting comments backed by data-driven arguments and intentional recommendations.4 R1 is proud to be a leader and advocate for policies that align with our mission–to reduce the friction that’s holding healthcare back and improving the patient financial experience.
1 CMS, Final Rule, 88 Fed. Reg. 22120 (Apr. 12, 2023), available at https://www.govinfo.gov/content/pkg/FR-2023-04-12/pdf/2023-07115.pdf..
2 As part of CMS’ rulemaking process, the agency releases its proposed rules prior to finalization and publication in the Federal Register. These rules typically improve current policies and regulations or implement new measures that affect providers and individuals partaking in CMS programs. The public is offered a chance to comment on proposed rules; comments are considered and may be incorporated into the agency’s final regulation.
3 CMS, Proposed Rule, 87 Fed. Reg.76,238 (Dec. 13, 2022), available at https://www.govinfo.gov/content/pkg/FR-2022-12-13/pdf/2022-26479.pdf.
4 R1’s comment on the proposed rule (available at https://www.regulations.gov/comment/CMS-2022-0190-0700) included a recommendation that PA determinations include flexibility for changes in a treatment plan. In the final rule published several weeks after our comment was submitted, CMS stated that for Medicaid Advantage plans, “an approval granted through PA processes must be valid for as long as medically necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.”
Author Bio: Content Written by R1's Regulatory Team
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