Health care organizations praise CMS new rules on prior authorizations, interoperability

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Medicare has the right idea in promulgating new rules regarding prior authorizations and interoperability in health care, according to national organizations dedicated to health care management, data sharing, and patient care.

On Jan. 17, 2024, the U.S. Centers for Medicare & Medicaid Services (CMS) announced regulations aimed at speeding up the prior authorization (PA) process and promoting greater interoperability. Known as CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), there will be new requirements starting in 2026 for payers to have quicker turnaround on requests for patient care, and more data sharing among payers and physicians and other clinicians.

The announcement prompted praise from the American Academy of Family Physicians (AAFP), the Medical Group Management Association (MGMA) and WEDI, the Workgroup for Electronic Data Interchange, an organization formed in 1991 to advise the U.S. Department of Health and Human Services on technology and health information sharing. They shared responses with news outlets shortly after the CMS press release.

‘Historic rule’

In a statement, WEDI President and CEO Charles Stellar called it “landmark regulation” and referred to APIs, the application programming interfaces that allow the various health care entities to trade information.

“Through the deployment of API technology, this historic final rule is expected to usher in a substantial reduction of administrative burden and unprecedented levels of health information exchange between health plans, providers, and the patients they serve,” Stellar said. “With stakeholders expected to face significant challenges adopting these new standards and revised workflows, WEDI will continue its role as convenor to identify solutions and best practices to ensure successful industry implementation.”

‘Egregious abuse’

Physicians have argued lengthy deliberations on prior authorization requests create unnecessary – even harmful – delays to treating patients. Even with increased attention by patients and lawmakers, in spring last year, MGMA reported it appeared the prior authorization process was getting worse, not better.

In a statement, MGMA Senior Vice President of Government Affairs Anders Gilberg said the organization supports the CMS directives.

“With prior authorization continuously ranking as the most burdensome regulatory issue facing medical groups, MGMA supports today’s action by CMS to finalize its proposals to streamline and standardize the process,” Gilberg said. “The increased transparency provisions – requiring health plans to provide clarity on the reasoning behind care denials and to publicly report aggregated metrics about their prior authorization programs annually – will help shine a light on the egregious abuse of prior authorization by payers under the guise of looking out for patients’ best interests. This final rule is an important step forward towards MGMA’s goal of reducing the overall volume of prior authorization requests – only then will medical groups find meaningful reprieve from these onerous, ill-intentioned administrative requirements that dangerously impede patient care.”

‘Improve access to primary care’

AAFP President Steven P. Furr, MD, FAAFP, cited MGMA data that almost 90% of physicians found prior authorizations to be very or extremely burdensome, and 97% of doctors said their patients face delays or denials for medically necessary care.

Now it is time for legislators to cement PA reform in law to help primary care physicians and their patients, Furr said in a statement.

“Electronic prior authorization will help cut down on the time physicians spend requesting and appealing coverage authorization from plans, as well as provide patients with more visibility into their care,” Furr said. “However, policymakers must also address the overwhelming volume of prior authorizations that physicians must complete. Physician practices are being forced to hire dedicated staff to handle prior authorizations instead of investing in staff or tools that would enhance patient care. Instead of interfering in the decisions family physicians make in consultation with their patients, our health care system should improve access to the primary care patients need.

“While this final rule is a concrete step toward reducing the glaring administrative burden physicians face, we need congressional action to cement this vital progress,” Furr said. “As such, family physicians urge Congress to swiftly pass the ‘Improving Seniors Timely Access to Care Act,’ which will streamline and standardize prior authorization under the Medicare Advantage program and protect beneficiaries from unnecessary delays in care. This will ensure physicians can do what they do best: treating patients.”