On January 17th, 2024, The Centers for Medicare & Medicaid (CMS), put forth the final rule for CMS Interoperability and Prior Authorization for payers and providers (CMS-0057-F). The final rule goes into effect as of 2026. The purpose of the final rule is to reduce patient, provider, and payer burdens by implementing a fluid set of processes which will assist the industry forward towards a fully electronic prior authorization model.
CMS has set the following to go in place:
Impacted payers must be ready to launch, all non-technical provisions by Jan. 1, 2026,
These payers must also meet application programming interface (API) development and enhancement requirements by Jan. 1, 2027.
Starting Jan. 1, 2027, impacted payers will be required to build and maintain a prior authorization API that automates three parts of the prior authorization process:
Identifying whether an item or service requires prior authorization.
Payer-specific documentation requirements; and
Exchanging prior authorization requests and responses.
Note: While certainly a mouthful, but a necessary one, it is important to know that CMS has named the Final Rule as follows: “Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program
The AMA conducted a survey in 2023 and published the results here: survey, https://www.ama-assn.org/system/files/prior-authorization-survey.pdf. The survey showed that close to 90% of those surveyed indicated that the overall taxing process of prior authorization posed a negative clinical impact within their practice. Furthermore, nearly 34% indicated some sort of adverse events arose out of the prior authorization process, up to and including death, hospitalization, disability or other life-threatening circumstances for patients in their care.
FACTS:
The average Medical Practice is completing approximately forty-five or more prior authorizations per provider, per week.
On average, Providers and staff spend upwards of approximately two business days a week completing prior authorizations.
Do no Harm – close to 25% of providers, have reported that the arduous steps they and their staff must go through to get proper care for their patient demographic, which unfortunately has led to negative and harmful effects on patients, up to and including death.
Negative Outcomes – upwards of almost 94%, of providers, have shown that they have been impacted with negative clinical outcomes with their patient demographic, due to the challenges of prior authorization, including ongoing delays and disruptions to patient care.
Patients Abandoning Treatment – approximately 78% of providers have reported a disturbing trend with their patient demographic that reflects many patients are opting out of treatment/care, due to the challenges they are also facing with their health care plans.
Additionally, the AMA survey posted results that clearly illuminate the deep concern over convoluted payer practices, when it comes to as I call it, “the prior authorization game of chance”. This report shows the overwhelming negative impact placed on the healthcare industry and damaging effects to patients and their overall healthcare experience. Let’s remember that patients and employers pay for Commercial healthcare and Medicare/Medicaid benefits are paid by both patients and our government, so payers have no right to intentionally deploy stall tactics aimed at reducing their own costs.
WHAT SHOULD MEDICAL PRACTICES DO?
We know that the Prior Authorization process is a multi-layered issue for much of the Healthcare industry and so tackling these issues head on is what is needed and that means having a department within your practice that is devoted to doing this task daily. The prior authorization process is time consuming for staff and with that comes slow/delayed response times, varying requirements payer to payer, including a variety of forms to be completed. In addition, payers can require peer-to-peer reviews and if the prior authorization is denied, staff must appeal it.
WHAT TO DO IF YOU GET A DENIAL FOR TREATMENT?
When a payer denies a request for treatment, after submitting a request for prior authorization, often the practice is met with a vague and vacuous response. The details are often muddied and there is no transparency or real guidance on what to do next. It is mission critical that you and your staff immediately reach back out to the payer and get on the phone and request an immediate peer to peer review and submit a letter of medical necessity to support the request. The squeaky wheel gets the oil as they say, and I personally have found this successful in getting a payer’s attention.
Still to come: CMS is still working with the AMA to develop future policies on prior authorization that will include drugs. Currently, payers have no true mandatory guidance they must follow in this category.
TIPS FOR PRIOR AUTHORIZATION DENIALS:
Immediately request a detailed explanation of the denial reason and who denied it, along with their credentials and full contact information
Immediately request a copy of the denial and a weblink to review the payers published medical policy and coverage rules that may have been referenced in the denial.
Immediately request what the payer requires to approve the treatment (prescription, DMD, surgery etc.), as well as any possible alternatives for care.
TOOLS FROM PAYER WEBSITES TO LOOK UP CPT/HCPCS ETC FOR PRIOR AUTHORIZATION INFORMATION:
https://med.noridianmedicare.com/web/jeb/cert-reviews/pre-claim
https://providers.anthem.com/new-york-provider/claims/prior-authorization-lookup-tool
RESOURCES:
AAPC Article: Interoperability and Prior Authorization Final Rule Explained
https://www.aapc.com/blog/90324-interoperability-and-prior-authorization-final-rule-explained/
When Prior Authorization Leads to Harm Caused by Delayed Care – by Thomas Law Offices
2024 CMS Interoperability and Prior Authorization final rule: Final rule, Fact Sheet
CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process
The CMS Final Rule is available at
MBR AAPC/NAMAS
Director of Compliance and Education, ZENMED Solutions INC.
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