CMS proposes new prior authorizations rule

December 11, 2020
Keith A. Reynolds

The proposed rule would improve the electronic exchange of healthcare data and streamline processes to reduce administrative burden.

The Centers for Medicare & Medicaid Services (CMS) seeking to improve the prior authorization problems.

According to a news release, the proposed rule would 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.

“This proposed rule ushers in a new era of quality and lower costs in health care as payors and providers will now have access to complete patient histories, reducing unnecessary care and allowing for more coordinated and seamless patient care,” CMS Administrator Seema Verma says in the release. “Each element of this proposed rule would play a key role in reducing onerous administrative burden on our frontline providers while improving patient access to health information.”

The proposed rule would require Medicaid, CHIP, and QHP insurers would be required 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 would also 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 would also have to provide specific reasons for any denial as well as make public certain metrics, according to the release.

The text of the proposed rule can be found here, and a copy of the factsheet can be found here.