CMS Proposes New Rules Around Prior Auths

by Shannon Firth: For Complete Post, Click Here…

Among other things, agency looks for ways to get rid of fax requirements.

The Centers for Medicare and Medicaid Services (CMS) proposed a new rule Thursday that aims to ease clinicians’ workload by streamlining prior authorizations (PAs) giving clinicians more time to see patients.

If you’re a physician, you probably already knew that because you already do PAs or have tasked your staff with them, and, based on our survey, you really, really hate them!!

“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,” said CMS Administrator Seema Verma, in a press release.

Proposed requirements for affected payers also include:

  • Build and maintain a Document Requirement Lookup Services (DRLS) API within the electronic health record, to help identify the prior authorization requirements of specific payers.
  • Build and maintain a “FHIR-enabled” electronic Prior Authorization Support API to send and receive PA requests electronically within their established work flow (while following HIPAA transaction standards).
  • Offer a specific reason for a denial of a prior authorization request to “facilitate better communication and understanding between the provider and payer” (this requirement would stand regardless of the method used to request the PA).
  • Send PA decisions within 72 hours for an urgent request and 7 days for standard requests (quality health plan issuers on the Fee for Service Exchanges are excepted).
  • Publicly share data about their PA process; for instance share of PA requests that are approved, denied and approved following appeal, and the average time between when a request is made and a determination.

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