As a rehab professional, is there anything more miserable than the gathering of stacks of documents and searching for records needed for pre-authorization?
Awful scans, missing documents, and most importantly wasted time…
I mean, we have patients to see, folks!
No one, and I mean no one, has time for that.
Well, some good news for all of you in the industry secondary to part of the Biden-Harris administration’s ongoing commitment to increasing health data exchange and investing in interoperability.
In December of 2022, the Centers for Medicare & Medicaid Services issued a proposed rule aimed at improving patient and provider access to health information and streamline processes related to prior authorization for medical items and services.
Yesterday, wasting no time, United Healthcare released their response to this proposal and would expect others to follow suit.
I also appreciate that most care providers don’t have time to read every fine line of proposed and final rules, so here is my attempt at an overview of the key points.
First, what is CMS’s goal here?
CMS proposes to modernize the healthcare system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent.
Second, how is data exchange between providers included as this is often the biggest headache?
The rule proposed to require certain payers to implement standards that would enable data exchange from one payer to another payer when a patient changes payers or has concurrent coverage, which is expected to help ensure that complete patient records would be available throughout patient transitions between payers.
Specifically, “CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” said CMS Administrator Chiquita Brooks-LaSure. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote healthcare data sharing to improve the care experience across providers, patients and caregivers — helping us to address avoidable delays in patient care and achieve better health outcomes for all.”
Sounds great! So how are we getting this done?
The proposed rule addresses challenges with the prior authorization process faced by providers and patients.
Proposals include requiring implementation of a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization.
Whew, that is a mouthful, but read that line and those terms again. In the future, they will become so commonplace in healthcare that we all must be comfortable with their use.
Ok, I get that, but what about all of the denials we are hearing about? How does this proposal address denials?
The proposal also includes requirements for certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests, which is twice as fast as the existing Medicare Advantage response time limit.
Finally, and most importantly, let’s review how this proposal aims to improve quality for patients.
The proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions.
This would be achieved via policies including:
- Expanding the current Patient Access API to include information about prior authorization decisions;
- Allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship;
- And creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.
The proposed rule is available to review here, with a recent deadline to submit comments is March 13, 2023.
Stacks of papers be gone! The world of automated pre-authorization is near but let us not celebrate prematurely.
The data and documentation to allow these systems to provide us the needed care allotments is still on us.
Time to stay tuned in to our managed payers response and ensure we continue to provide all needed information to promote the highest possible care delivery for those we serve.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected].
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.