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CMS leaders tout prior authorization rule among 2023 accomplishments, 2024 agenda

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New regulations aim to make prior auths faster and clearer for physicians and patients.

medical doctor drawing medicare on virtual screen: © WrightStudio - stock.adobe.com

© WrightStudio - stock.adobe.com

Physicians, beneficiaries and government leaders made 2023 a year to celebrate for Medicare and Medicaid, and the U.S. Centers for Medicare & Medicaid Services (CMS) have an ambitious agenda for 2024, the agency's leader said.

On Jan. 23, CMS Administrator Chiquita Brooks-LaSure and her top aides hosted their first-quarter National Stakeholder Call, broadcast online with more than 2,000 participants listening in.

Less than a week ago, CMS published its new rule governing prior authorizations and interoperability, expected to save $15 billion over 10 years while smoothing out medical care approval processes for patients, physicians and payers.

Brooks-LaSure counted that among the agency’s accomplishments and said the new rule and other changes are reflective of CMS listening to feedback “about the pressing issues that happen in the lives of providers and Americans, and we are listening.”

“It is critical that prior authorization not be an impetus to keeping people from getting care, but as an improvement to improve their care,” Brooks-LaSure said.

She said “2023 was nothing short of extraordinary,” and she thanked those who worked with programs and beneficiaries to help CMS.

“We have an ambitious agenda for 20204,” Brooks-LaSure said. “All of our work is focused on working to ensure that all the people covered under programs have a just opportunity to obtain their optimal health, no matter what they look like, where they live, or how much money they have. Health equity will always be a cornerstone for our programs and initiatives.”

Prior authorizations getting easier

Stace Mandl, acting director of the CMS Office of Burden Reduction & Health Informatics, used her time to detail the new requirements. The rule formally is known as the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).

“The final rule will reduce burden for patients providers and payers by streamlining prior authorization processes and moving the industry toward electronic prior authorization,” Mandl said. “These changes will help patients access care in a timely manner and enable clinicians to spend more time focusing on direct patient care. This rule also demonstrates our continued commitment to ensuring that health information is readily available to the right person at the right place and at the right time.”

  • CMS will use application programming interfaces, or APIs, that allow different computer systems to talk with one another, Mandl said. The new prior authorization API will help automate the PA process with information such as the reasons for items and services, and what documentation is needed to support PA requests.
  • Affected payers are required to send prior authorization decisions for standard requests within seven days and decisions for expedited requests are due in 72 hours, starting in 2026.
  • If care is denied, payers must provide specific reasons, making appeals easier.
  • Payers must publicly report certain PA metrics.

The existing patient access API will be expanded to include PA information, granting more information to patients. The new private provider access API will enable patients to allow their providers easier access to health data from payers, facilitating better care coordination and decision-making, Mandl said.

“We are excited to continue this work by exploring additional opportunities to streamline the prior authorization process and we look forward to engaging with all of you on additional ways we can support the health care workforce and return time back to patient care,” Mandl said.

Additional work

Brooks-LaSure and the other leaders provided a list of accomplishments across the three M’s – Medicare, Medicaid and the Children’s Health Insurance Program, and the Marketplaces, the health insurance programs available through the Affordable Care Act. Last year, the three served 160 million people, and the ACA Marketplace insurance for 2024 hit a record 20 million and counting, she said.

  • The Inflation Reduction Act has “landmark reforms” that already are lowering prescription drug prices and capping insulin costs.
  • Drug companies must pay rebates if they hike prices faster than inflation.
  • Medicare now has authority to negotiate drug prices for conditions such as cardiovascular disease, diabetes, Crohn disease and rheumatoid arthritis.
  • Medicare beneficiaries will have limits to their out-of-pocket costs.
  • Medicaid and CHIP access has expanded to 43 states, Washington, D.C., and the U.S. Virgin Islands with expanded postpartum coverage to 12 months.
  • Medicare now is covering marriage and family therapists, with more than 11,000 mental health counselors and more than 1,700 marriage and family therapists enrolled to provide behavioral health services.

Additional speakers included Meena Seshamani, MD, PhD, deputy administrator and Medicare Center director; Ellen Montz, PhD, deputy administrator and director of the Center for Consumer Information and Insurance Oversight; Sara Vitolo, deputy director of the Center for Medicaid and CHIP Services director; Dora Hughes, MD, MPH, acting CMS chief medical officer and director of the Center for Clinical Standards and Quality; Elizabeth Fowler, PhD, JD, deputy administrator and director of the Center for Medicare and Medicaid Innovation; Dara Corrigan, deputy administrator and director of the CMS Center for Program Integrity; Aditi Mallick, MD, acting director of the office of minority health; and Eden Tesfaye, adviser to the administrator for external affairs.

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Mike Bannon - ©CSG Partners