CMS Wants To Force Insurers To Ease Prior Authorization

The Trump administration on Thursday proposed changes that aim to improve patient and provider access to medical records and reform prior authorization.

The proposed rule would require payers—including Medicaid, the Children’s Health Insurance Program and exchange plans—to build application program interfaces to support data exchange and prior authorization. According to CMS, the changes would allow providers to know in advance what documentation each payer would require, streamline documentation processes and make it easier for providers to send and receive prior authorization information requests and responses electronically.

“Prior authorization is a necessary and important tool for payors to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing administrative costs for the whole system,” CMS Administrator Seema Verma said in a statement.

According to CMS, the plan builds on the interoperability regulations approved by the agency in May.

“These policies, taken together, could lead to fewer prior authorization denials and appeals while improving communication and understanding between payers, providers and patients,” the agency said in a statement.

Comments on the proposed rule close Jan. 4. The agency wants it to take effect on Jan. 1, 2023.

Under the proposal, payers would have to build and maintain application program interfaces using the Health Level 7 Fast Healthcare Interoperability Resources—FHIR—standard.

It would also reduce the time insurers have to inform providers about prior authorization decisions. Payers would have 72 hours to respond to urgent prior authorization requests—except for plans sold on federally-run exchanges—and seven 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,” CMS said in a statement.

The agency is considering a similar proposal for Medicare Advantage plans.

Application programming interfaces allow electronic health records and other information systems to talk to each other or third-party applications. They’ve been a key part of the Trump administration’s effort to make it easier for providers, insurers and patients to share health-related information. But key players in the healthcare industry have resisted adoption because of privacy and implementation concerns.


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