{"id":1704,"date":"2024-06-28T16:17:23","date_gmt":"2024-06-28T16:17:23","guid":{"rendered":"https:\/\/zenmedinc.com\/blog\/?p=1704"},"modified":"2024-08-27T05:42:25","modified_gmt":"2024-08-27T05:42:25","slug":"navigating-the-prior-authorization-conundrum","status":"publish","type":"post","link":"https:\/\/zenmedinc.com\/blog\/navigating-the-prior-authorization-conundrum\/","title":{"rendered":"NAVIGATING THE PRIOR AUTHORIZATION CONUNDRUM"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"1704\" class=\"elementor elementor-1704\">\n\t\t\t\t<div class=\"elementor-element elementor-element-661e2b4 e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"661e2b4\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b57558d elementor-widget elementor-widget-text-editor\" data-id=\"b57558d\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">On January 17th, 2024, The Centers for Medicare &amp; 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. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>CMS has set the following to go in place:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Impacted payers must be ready to launch, all non-technical provisions by Jan. 1, 2026, <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">These payers must also meet application programming interface (API) development and enhancement requirements by Jan. 1, 2027.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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:<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Identifying whether an item or service requires prior authorization.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Payer-specific documentation requirements; and<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Exchanging prior authorization requests and responses.<\/span><\/span><\/p><\/li><\/ul><p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>Note:<\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"> While certainly a mouthful, but a necessary one, it is important to know that CMS has named the Final Rule as follows<\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><i>: \u201cMedicare 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\u2019s 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<\/i><\/span><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">The AMA conducted a survey in 2023 and published the results here: survey, <\/span><\/span><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.ama-assn.org\/system\/files\/prior-authorization-survey.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.ama-assn.org\/system\/files\/prior-authorization-survey.pdf<\/span><\/span><\/a><\/u><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">. <span style=\"color: #000000;\">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. <\/span><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>FACTS:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">The average Medical Practice is completing approximately forty-five or more prior authorizations per provider, per week.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">On average, Providers and staff spend upwards of approximately two business days a week completing prior authorizations.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Do no Harm \u2013 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.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Negative Outcomes &#8211; 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.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Patients Abandoning Treatment \u2013 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. <\/span><\/span><\/p><\/li><\/ul><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Additionally, the AMA survey posted results that clearly illuminate the deep concern over convoluted payer practices, when it comes to as I call it, \u201cthe prior authorization game of chance\u201d. This report shows the overwhelming negative impact placed on the healthcare industry and damaging effects to patients and their overall healthcare experience. Let\u2019s 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. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>WHAT SHOULD MEDICAL PRACTICES DO?<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>WHAT TO DO IF YOU GET A DENIAL FOR TREATMENT?<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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\u2019s attention. <\/span><\/span><\/p><p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>Still to come:<\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"> 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. <\/span><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>TIPS FOR PRIOR AUTHORIZATION DENIALS:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Immediately request a detailed explanation of the denial reason and who denied it, along with their credentials and full contact information<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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.<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Immediately request what the payer requires to approve the treatment (prescription, DMD, surgery etc.), as well as any possible alternatives for care. <\/span><\/span><\/p><\/li><\/ul><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>TOOLS FROM PAYER WEBSITES TO LOOK UP CPT\/HCPCS ETC FOR PRIOR AUTHORIZATION INFORMATION:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cgsmedicare.com\/medicare_dynamic\/jb\/pa\/pa.aspx\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cgsmedicare.com\/medicare_dynamic\/jb\/pa\/pa.aspx<\/span><\/span><\/a><\/u><\/span><\/p><\/li><li><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/med.noridianmedicare.com\/web\/jeb\/cert-reviews\/pre-claim\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/med.noridianmedicare.com\/web\/jeb\/cert-reviews\/pre-claim<\/span><\/span><\/a><\/u><\/span><\/p><\/li><li><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/providers.anthem.com\/new-york-provider\/claims\/prior-authorization-lookup-tool\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/providers.anthem.com\/new-york-provider\/claims\/prior-authorization-lookup-tool<\/span><\/span><\/a><\/u><\/span><\/p><\/li><li><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/medicare.fcso.com\/prior_authorization\/index.asp\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/medicare.fcso.com\/prior_authorization\/index.asp<\/span><\/span><\/a><\/u><\/span><\/p><\/li><\/ul><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>RESOURCES:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">AAPC Article: Interoperability and Prior Authorization Final Rule Explained<\/span><\/span><\/p><\/li><\/ul><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.aapc.com\/blog\/90324-interoperability-and-prior-authorization-final-rule-explained\/\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.aapc.com\/blog\/90324-interoperability-and-prior-authorization-final-rule-explained\/<\/span><\/span><\/a><\/u><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">When Prior Authorization Leads to Harm Caused by Delayed Care \u2013 by Thomas Law Offices<\/span><\/span><\/p><\/li><\/ul><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.thomaslawoffices.com\/blog\/insurance-bad-faith\/when-prior-authorization-leads-to-harm-caused-by-delayed-care\/\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.thomaslawoffices.com\/blog\/insurance-bad-faith\/when-prior-authorization-leads-to-harm-caused-by-delayed-care\/<\/span><\/span><\/a><\/u><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">2024 CMS Interoperability and Prior Authorization final rule: Final rule, Fact Sheet<\/span><\/span><\/p><\/li><\/ul><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/newsroom\/fact-sheets\/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f<\/span><\/span><\/a><\/u><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process<\/span><\/span><\/p><\/li><\/ul><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/newsroom\/press-releases\/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/newsroom\/press-releases\/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process<\/span><\/span><\/a><\/u><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">The CMS Final Rule is available at<\/span><\/span><\/p><\/li><\/ul><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/files\/document\/cms-0057-f.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/files\/document\/cms-0057-f.pdf<\/span><\/span><\/a><\/u><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>On January 17th, 2024, The Centers for Medicare &amp; 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<\/p>\n","protected":false},"author":2,"featured_media":1783,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[16],"tags":[27,26,40],"class_list":["post-1704","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicare","tag-medicaid","tag-medicare","tag-prior-authorization-and-payers"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>NAVIGATING THE PRIOR AUTHORIZATION CONUNDRUM - ZenMed Solutions Inc<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/zenmedinc.com\/blog\/navigating-the-prior-authorization-conundrum\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"NAVIGATING THE PRIOR AUTHORIZATION CONUNDRUM - ZenMed Solutions Inc\" \/>\n<meta property=\"og:description\" content=\"On January 17th, 2024, The Centers for Medicare &amp; Medicaid (CMS), put forth the final rule for CMS Interoperability and Prior Authorization for payers and providers (CMS-0057-F). 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