CMS proposes new rule to simplify prior authorizations

CMS issued a proposed rule Dec. 10 to streamline prior authorizations and create a better exchange of healthcare data between payers, providers and patients. 

Under the proposed rule, payers in Medicaid, Children's Health Insurance Program and Qualified Health Plan would build application programming interfaces to ease data exchange and prior authorizations.

Application programming interfaces allow two entities to communicate and share healthcare data electronically. Under the proposed rule, payers would be required to maintain these interfaces using the Health Level 7 Fast Healthcare Interoperability Resources standard, a technology-based tool to help close data gaps between systems.

"Prior authorization is not only a leading source of burden, it is also a primary source of provider burnout, and takes time away from treating patients," CMS Administrator Seema Verma said in a news release. "If just a quarter of providers took advantage of the new electronic solutions that this proposal would make available, the proposed rule would save between $1 billion and $5 billion over the next 10 years. With the pandemic placing even greater strain on our healthcare system, the policies in this rule are more vital than ever.'

In a Dec. 11 statement, the American Hospital Association called the proposal  "a welcome step toward helping clinicians spend their limited time on patient care," but also said it is "deeply disappointed" CMS did not include Medicare Advantage plans in the rule.

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