Hospitals urge CMS to fix 'problematic' prior authorization process

On behalf of its nearly 5,000 member hospitals and health systems, the American Hospital Association is urging CMS to revise proposed regulations around prior authorizations and address "problematic" usage of prior authorizations by certain Medicare Advantage health plans. 

Prior authorizations are a process in which a provider, on behalf of a patient, requests approval from the patient's insurer to ensure the treatment or service will be covered. This process, while designed to ensure patients are receiving care in the right setting based on efficacy and safety, can be cumbersome for providers as many plans have different requirements and submission guidelines. 

To help streamline prior authorizations, CMS proposed a rule Dec. 10 called the Reducing Provider and Patient Burden by Improving Prior Authorization Processes and Promoting Patients' Electronic Access to Health Information. If the rule is finalized, the regulation would create a standard method to determine if a procedure needs prior authorization, a standard process to submit the prior authorization and supporting documentation, and a standard process for getting a determination from a health plan. The rule, as it was written, requires payers in Medicaid, Children's Health Insurance Program and Qualified Health Plan to adhere to the new requirements.

While the AHA supports the proposed rule, the hospital lobby argues it is missing a key player: Medicare Advantage Organizations.

"The notable exclusion of MAOs is extremely troubling and significantly reduces the potential impact of the regulation," the AHA wrote. "In order to promote procedural improvements and prevent negative health outcomes associated with delays in care for all beneficiaries, we urge CMS to require MAOs to adhere to the requirements set forth in this proposal."

The AHA said that including MA plans would also reduce administrative burdens and costs for providers because it would cut down on variation between plans. 

The AHA also called on CMS to modify the proposed rule to require MA plans to automatically consider a service authorized when the provider rendering the service has a history of prior authorization approval of 90 percent or higher. 

"This approach would go a long way in reducing unnecessary care delays and clinician burden while giving the plan the ability to ensure care adheres to the patient's coverage rules," the AHA said.

The AHA is also urging CMS to reduce the amount of time health plans have to render a prior authorization decision. Under current regulation, MA plans have 14 days to respond to a prior authorization request. The AHA is asking CMS to mandate health plans to deliver a prior authorization approval or denial within 72 hours for standard non-urgent care and 24 hours for urgent services. 

"Health plans have the capability to determine whether the patient meets the medical necessity threshold in a more timely manner, particularly as the industry implements technology improvements that enable timely information exchange," the AHA wrote. 

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