ACP Calls for Changes to Prior Authorization System That Prioritize Patients and Physicians

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CMS is working to streamline the process, proposes reduction in amount of time physicians need to wait for decisions on requests from payers

April 7, 2023 (ACP) — As the Centers for Medicare & Medicaid Services (CMS) prepares to overhaul the prior authorization system, the American College of Physicians is weighing in with a call for sensible reform that prioritizes the interests of patients and clinicians.

“Members have consistently said that prior authorization is among the highest sources of burden for them and their practices, if not the highest,” said Brian Outland, ACP director of regulatory affairs. “Data from our member surveys have reflected and confirmed this sentiment.”

In a March 13 letter to the administrator of CMS, ACP leaders responded to a request for comment by highlighting the importance of streamlining the prior authorization process.

“There is a need for real-time decisions with respect to prior authorization requests, as receiving a response to a prior authorization request after the patient has left the office causes additional, unnecessary administrative work outside of the patient visit and can delay appropriate treatment for the patient. A timely response at the point of care is integral to streamlining this process,” Dr. Deepti Pandita, chair of the ACP Medical Informatics Committee, and Dr. William Fox, chair of the ACP Medical Practice and Quality Committee, wrote in the letter.

CMS agrees that the process should be streamlined and is proposing that Medicare Advantage organizations, state Medicaid, the Children's Health Insurance Program and federally facilitated marketplace health plans put new software into place by 2026.

“In tackling the current roadblocks, the proposed rule would reduce the amount of time physicians have to wait for a decision from a payer on a prior authorization request. CMS has proposed to cap this time at a 72-hour limit for payers for urgent requests and seven days for nonemergency requests,” Outland explained. “This is twice as fast as the existing Medicare Advantage response time limit. The agency also included proposals to require payers to provide a specific reason when they deny a request, as well as rules that would engage a longitudinal health record should the patient opt into data sharing.”

In a separate proposed regulation, CMS is also seeking to require that Medicare Advantage organizations implement requirements that: prior authorization policies for coordinated care programs may only be used to confirm the presence of diagnoses or other clinical criteria and/or ensure that an item or service is medically necessary; a minimum 90-day transition period must be allowed when an enrollee currently undergoing treatment switches to a new Medicare Advantage plan; and a Utilization Management Committee must review policies annually and ensure consistency with traditional Medicare national and local coverage decisions and guidelines.

As noted in its position paper “Putting Patients First by Reducing Administrative Tasks in Health Care,” ACP believes that “payers, public and private oversight entities, and vendors and suppliers must work together and actively engage with clinician societies and frontline clinicians to harmonize their administrative policies, procedures, processes, and forms regarding such issues as prior authorizations.”

ACP adds that “to facilitate the elimination, reduction, alignment, and streamlining of administrative tasks, all key stakeholders should collaborate in better utilizing existing health information technologies, as well as developing more innovative approaches.”

In addition, “restructuring digital approaches to collecting, sharing, and reporting information and responding to requests should be a top priority of key stakeholders and implemented in a manner that involves direct input from frontline clinicians and patients to ensure that these approaches are affordable and truly meet their needs.”

For the most part, CMS proposals “would align closely with those issued by ACP in its position paper in that electronic standards and processes would be implemented to greatly simplify certain aspects of prior authorization,” Outland said. “The College believes these proposals align with the agency's ongoing work to strengthen patient access to care and reduce these burdens, and we commend CMS for issuing proposals that mirror provisions in the Improving Seniors' Timely Access to Care Act,” which is a bill that the College has been advocating for Congress to move forward.

However, ACP is disappointed that the proposals do not apply to Medicare fee-for-service and exclude medications, Outland noted. In addition, he said, “the College also thinks that response times for prior authorization decisions should be even shorter than those proposed in the rule, and that the rule should take effect earlier than 2026.”

At this point, it is not known which proposals from the rule will become final or when, Outland said. The proposed regulations that update the Medicare Advantage program would go into effect as soon as Jan. 1, 2024, according to Outland, while the other proposed changes would take effect on Jan. 1, 2026.

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