New Proposed Rule from CMS: Addressing Prior Authorization and Increasing Access to Medical Records

Today, CMS issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients, and would streamline processes related to prior authorization to reduce burden on providers and patients. We have heard similar claims from CMS in the past, it remains to be seen if this rule (if finalized in its current form) would genuinely reduce provider burden and compliance costs.

The rule would require payers in Medicaid, CHIP and QHP programs to build application programming interfaces (APIs) to support data exchange and prior authorization. APIs allow two systems, or a payer’s system and a third-party app, to communicate and share data electronically  Payers would be required to implement and maintain these APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard.

Theoretically, this system will allow providers to know what documentation each payer requires, and enable providers to send prior authorization requests and receive responses directly from the provider’s EHR or other practice management system.

The proposed rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers—the rule proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the FFEs, to issue decisions on urgent requests and seven calendar days for non-urgent requests. Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing. 

The rule would also allow patients to have “portable data,” that they can move from payer to payer as their health insurance changes. Payers will have to make patient data available in a standardized format that is compatible with all other payers.

For more information, check out the following resources from CMS:

Press Release

Fact Sheet

CMS Health Informatics Webpage

Proposed Rule (Full)

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