A new proposed rule released by the Centers for Medicare & Medicaid Services aims to ease prior authorization burdens in the Medicaid system, state exchanges created under the Affordable Care Act and the Children’s Health Insurance Program. A Centers for Medicare & Medicaid Services release said the rule also aims to improve patient data-sharing between health care providers and simplify prior authorizations.
“Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients,” CMS Administrator Seema Verma said in the release.
The proposed rule, which would take effect in 2022, specifically seeks to improve slow approvals. For Medicaid and Children’s Health Insurance and Affordable Care Act plans affected, it would require:
- 72-hour approvals for cases requiring “expedited decisions”
- Seven-day approvals for “standard decisions”
The rule also would require payers to give a reason for the denial, which they don’t currently have to do, and would speed communication and sharing data electronically.
The Academy will formally comment on the rule by the Jan. 4 deadline. The Federal Register will publish the proposed rule Dec. 18.
The rule does not address settings where ophthalmologists have encountered the greatest prior authorization burdens: Medicare Advantage plans or the new requirements in fee for service Medicare implemented for the hospital outpatient department setting. Prior authorization denials are one of the costliest revenue cycle issues affecting all medical practices and health systems. The Academy and the Regulatory Relief Coalition, of which the Academy is a founding member, has been meeting with CMS over the past two years sharing recommendations such as automated approvals to lower burdens and speed treatment for patients in ophthalmology practices.
The Academy has consistently raised concerns about prior authorizations with CMS, advocating for an end to prior-authorization abuses in Medicare Advantage and urging the agency to give Medicare Advantage plans guidance on how and when to use the tool.
Senate Bill Seeks to Improve Transparency and Ease Administrative Burdens
We also continue to push for legislative relief from prior authorization burdens in the Medicare Advantage program. This week, Sens. Sherrod Brown, D-Ohio and John Thune, R-N.D introduced a Senate companion bill to HR 3107, the Improving Seniors' Timely Access to Care Act, which was introduced in 2019.
This bipartisan bill seeks to reform the use of prior authorization in Medicare Advantage through a streamlined and standardized process that focuses on increased transparency. Specifically, the bill would call on the secretary of the Department of Health and Human Services to:
- Establish a real-time, electronic prior authorization process
- Minimize the use of prior authorization for routinely approved services
- Ensure prior authorization requests are reviewed by qualified medical personnel
- Require transparency through regular reporting from Medicare Advantage plans on their use of prior authorization, as well as rates of delay and denial of services, and for determinations that occur in the context of surgeries or other invasive procedures.
Throughout the year, the Regulatory Relief Coalition has pushed for passage of the House bill, which has nearly 300 co-sponsors in the U.S. House.
Reps. Suzan DelBene, D-Wash.; Mike Kelly, R-Penn.; Ami Bera, MD, D-Calif.; and Roger Marshall, MD, R-Kan., co-sponsored the House bill. They have worked closely with the Senate sponsors on development of their companion bill.
Passage of the bill is unlikely this late in the legislative session. However, introducing the Senate prior authorization bill now could set up action early in the new 117th Congress that convenes in January.