AHIP decries new prior authorization rule

January 18, 2021
Keith A. Reynolds

The president of America’s Health Insurance Plans says the new private rule is a series of empty promises.

America’s Health Insurance Plan (HCIP) says that the new prior authorization rule from the Centers for Medicare & Medicaid Services (CMS) misses the mark.

In a statement, President and CEO Matt Eyles says that that AHIP’s member organizations work to harness new technologies in sharing information with patients and physicians in a secure fashion.

“Unfortunately, today’s final rule from CMS is largely a series of empty promises,” Eyles says in the release. “This shabbily and hastily constructed rule puts a plane in the air before the wings are bolted on by requiring health insurance providers to build these technologies with incomplete and untested instruction manuals. And, despite rushing the rule, this Administration requires insurance providers to build expensive IT bridges to nowhere by failing to establish comparable requirements for providers or their IT vendors to use the technologies.”

Eyles says that the Trump administration conducted the shortest rulemaking process “that anyone can remember,” which afforded stakeholders only 14 business days to comment.

“Miraculously, the (a)dministration was able to provide the ‘reviews’ and ‘responses’ in less than nine business days despite over 250 stakeholders filing thousands of pages of public comments,” Eyles says. “This was wholly inadequate to allow stakeholders to conduct appropriate analyses and was clearly not consistent with the thoughtful notice-and-comment approach to developing policies that is customarily afforded a rule estimated to cost nearly $3 billion to implement.”

As previously reported, the new rule will improve the electronic exchange of healthcare data between insurers, physicians, and patients and streamlining the processes related to the prior authorization to reduce administrative burden.

The new rule requires Medicaid, CHIP, and QHP insurers to build and implement Fast Healthcare Interoperability Resources (FHIR) standard enabled application programming interfaces (API) that could allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or other practice management system, the release says.

It is expected to reduce physician prior authorization wait times by proposing a 72-hour maximum to issue decisions on urgent requests and seven calendar days for non-urgent ones. Insurers will also have to provide specific reasons for any denial as well as make public certain metrics, according to the release.

The full text of the final rule can be found here.