CMS Final Rule: Streamlining the Prior Authorisation Process

By Danélia Botes

February 5, 2024

Introduction:

The Biden-Harris administration has made a huge step toward improving health data interchange and strengthening access to care, which is a move that has the potential to completely transform the competitive landscape. The Centers for Medicare & Medicaid Services (CMS) has finalised the CMS Interoperability and Prior Authorisation Final Rule (CMS-0057-F), a milestone in the journey towards a more efficient healthcare system.

A New Era for Medicare Advantage:

This rule imposes requirements on Medicare Advantage (MA) organisations, Medicaid, the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, and other entities, collectively known as ‘impacted payers’. The aim is to optimise the electronic exchange of health information and streamline prior authorisation processes for medical items and services.

The Impact on Patients, Providers, and Payers:

These policies are set to improve prior authorisation processes, reducing the burden on patients, providers, and payers. Many Americans, undoubtedly, experience prolonged delays in authorisations from insurance companies for their healthcare needs. The expected savings are estimated at approximately $15 billion over a decade. This move is expected to shorten approval wait times and better digitise the approval process, thus enhancing the patient experience and healthcare outcomes.

CMS on Eliminating Systemic Barriers:

Chiquita Brooks-LaSure, the CMS Administrator, has affirmed the organisation’s dedication to eliminating barriers within the healthcare system. The purpose of this is to streamline the process for healthcare providers to deliver essential care with more ease. The methods to accomplish this objective involve optimising productivity, guaranteeing smooth and protected transmission of information between patients, healthcare providers, and insurance companies, and streamlining the procedures for obtaining prior authorisation.

Streamlining the Prior Authorisation Process:

The new rule mandates that certain payers simplify the prior authorisation process. All affected payers must give a specific reason if they deny a prior authorisation request. This information will help with resubmission or appeal of the request when necessary. For expedited (urgent) medical products and services, affected payers must make prior authorisation decisions within 72 hours. For standard requests, they must make decisions within seven calendar days. These requirements will take effect in 2026. Therefore, this new standard request timeframe halves decision times for some payers.

The Power of Technology in Healthcare:

The rule also necessitates impacted payers to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorisation application programming interface (API), which is a standard for exchanging health care information electronically. This will automate the end-to-end prior authorisation process, reducing administrative burden on the healthcare workforce, and preventing avoidable delays in care for patients.

Conclusion:

In conclusion, the CMS Interoperability and Prior Authorisation Final Rule is set to redefine the healthcare sector. It prioritises simplifying the prior authorisation process and reducing administrative tasks. Moreover, it also equips the power of technology to improve patient care, boost healthcare outcomes, and cut costs. This rule underscores the importance of seamless data exchange and interoperability in healthcare. It propels the industry towards a more integrated, patient-focused approach. This represents an important achievement in enhancing the healthcare system and establishes a model for forthcoming healthcare policies.

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