Providers want more time to understand prior authorization changes

Healthcare insiders are pressing the Trump administration to extend the public comment period for a proposed rule that aims to reform prior authorization and improve patient and provider access to medical records, according to comments on the proposed rule due Monday.

CMS on Dec. 10 unveiled its plan to require payers—including Medicaid, the Children’s Health Insurance Program and exchange plans—to build application program interfaces to support data exchange and prior authorization. It said the changes would allow providers to know in advance what documentation each payer would require, streamline documentation processes and make it easier for providers to send and receive prior authorization information requests and responses electronically.

Comments on the proposed rule closed Monday, just 22 days after CMS made it public. Industry groups, state officials and policy experts argue they need more time to review the proposal given its complexity and CMS’ multiple requests for information.

The Medicaid and CHIP Payment and Access Commission, a congressional advisory panel, said “the period allowed for public comment—just 17 days spanning a period with three federal holidays—is insufficient.” It noted that federal law usually requires a 30-day notice and comment period for proposed rules unless agencies have “good cause” to skip the requirement when it’s in the public interest, such as during a public health emergency like the COVID-19 pandemic.

“However, the notice of proposed rulemaking makes no mention of good cause and provides no explanation for the shortened comment period,” MACPAC’s letter said.

Industry groups stressed that they didn’t have enough time to give CMS “comprehensive, thoughtful and detailed feedback,” according to a letter signed by several organizations. The American Academy of Family Physicians, American Hospital Association, Medical Group Management Association, Premier Healthcare Alliance and other key groups signed onto it.

“The rule includes a number of requests for information on a wide range of topics,” the letter said. “Each of these RFIs will require careful consideration and may require outreach to our members to appropriately respond.”

It’s unclear why CMS chose such a short comment period. But it’s likely part of the Trump administration’s final push to advance its healthcare agenda, which has focused on increasing interoperability and reducing administrative work for providers.

Providers offered lukewarm support for the proposal, saying they favored the agency’s effort to streamline prior authorization across payers, despite their general opposition to prior authorization.

“We support initiatives that standardize data and processes around ordering services and related prior authorization, and that automate ordering and prior authorization processes through adoption of standardized templates and data elements,” the Association of American Medical Colleges wrote.

But providers and policy experts took issue with CMS’ decision to exclude Medicare Advantage organizations from the proposed rule, arguing that “adopting a standardized, straightforward form of requirements and process for prior authorization for all payers would reduce burden,” according to AAMC.

“CMS should at a minimum also include MA organizations as payers that must comply with the proposed prior authorization practices, considering the continued growth of Medicare beneficiaries enrolling in MA plans,” AAMC’s letter said.

MACPAC was especially concerned about how the policy could affect people eligible for both Medicare and Medicaid. The advisory panel pointed out that CMS said in the proposed rule that excluding Medicare Advantage organizations would “create misalignments between Medicaid and Medicare that could affect dually eligible individuals enrolled in both a Medicaid managed care plan and an MA plan.”

“Given current misalignments between the two programs that complicate the ability to integrate care for this high-cost, high-need population, MACPAC questions the wisdom of creating additional ones,” MACPAC’s letter said.

State Medicaid officials balked at the administration’s latest effort to build on its interoperability rule, which is rolling out over the next two years, saying they’re already overwhelmed by the ongoing changes, COVID-19 and budget problems. The National Association of Medicaid Directors said it’s “premature” for CMS to create new interoperability requirements for states since the agency doesn’t know how the current requirements will work in practice.

“It will likely take several years for API developers to leverage the APIs states and managed care plans are implementing now. Real-world experience from these APIs, once they are implemented, should be evaluated and lessons learned applied to future policymaking,” NAMD’s letter said. “This proposed rule does not currently allow for those lessons to be learned.”


Tags: covid-19, pandemic

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