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ACP Supports Changes to CMS Prior Authorization Rule, but Concerned Not All Aspects Addressed

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CMS allowed for only a 25-day comment period, rather than typical 30 to 60 days, which ACP says did not allow for sufficient time for feedback

Jan. 22, 2021 (ACP) – The Centers for Medicare & Medicaid Services (CMS) finalized the “Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients' Electronic Access to Health Information” rule in mid-January, which outlines an extensive list of technical requirements aiming to improve data exchange while reducing physician and patient burden. Although the American College of Physicians has long advocated for reducing prior authorization burden, there is concern that the agency moved forward with this rule without sufficient time to review comments from stakeholders.

“We applaud CMS for their continued focus on these important issues of reducing burden and incorporating technical fixes to do so,” said Brooke Rockwern, ACP senior associate of health IT policy. “However, a big part of our messaging around reducing burden is how important it is to involve all necessary stakeholders in the policy development and implementation process to ensure that what is being done is actually reducing burden. It's crucial that various voices be part of the process.”

In a Jan. 4 letter to CMS Administrator Seema Verma, Dr. Zeshan A. Rajput, chair of the ACP Medical Informatics Committee, wrote that ACP is “very disappointed that the Agency only allowed for a 25-day comment period for industry stakeholders to provide feedback on important burden reduction proposals. The requirements and specifications outlined in the proposed rule are highly technical and warrant thoughtful feedback from the community who will be implementing and abiding by these new requirements.”

As Rockwern explained, CMS is taking important policy steps in an attempt to decrease administrative burden. “Their proposals for the adoption and consistent implementation of health IT standards and application programming interfaces will help reduce variability across electronic health records (EHRs) and health IT systems,” she said. “However, the complex nature of our health care system requires these types of technical proposals to be accompanied with other nontechnical changes, such as policies requiring private insurers to harmonize their various prior authorization requirements. These will make sure the new functionality doesn't end up decreasing EHR usability and increasing burden.”

Rockwern said ACP would have liked to see certain parts of the administrative process automated to ease the burden for physicians and patients. “Filling out a different form for each payer interaction, even if one is able to search for the payer's specific requirements within a database, is still burdensome, regardless of the type of technologies used,” she said.

Also, according to Rockwern, CMS did not include Medicare Advantage plans in these policies, “essentially leaving out a huge portion of payers that are the source of a lot of the prior authorization burden,” she said. “The proposals don't cover prior authorizations for medications either – that is another area where there is a high frequency of prior authorizations and a pretty significant gap in the regulation.”

Federal officials should have allowed for a much longer comment period, Rockwern said. “Agencies give at least 30 to 60 days for public comment,” she said. “Given the technical nature of the proposals, as well as the numerous requests for information included within the proposed rule, it warranted the full 60-day comment period to allow for thoughtful feedback from all stakeholders.”

Despite the comments from ACP and other stakeholders, the agency moved quickly to finalize the rule before the new administration took office. “Reducing administrative burdens has been a top priority of the previous administration and one of the policy areas where the College has really been able to collaborate,” Rockwern said. “CMS has also been very engaged in the health IT components of reducing burden and collaborating a lot with the Office of the National Coordinator for Health IT (ONC). Prior authorization in particular is one of the most burdensome administrative processes identified by physicians and patients – and both CMS and ONC have prioritized streamlining the process.”

Although the new regulations are now final, there is good news: They won't go into effect for a few years. “Hopefully, there is time to revisit the proposals and possibly make necessary updates in future rulemaking,” Rockwern said.

For now, she said, “reducing prior authorization burden is a top ACP priority, and the College will continue to advocate putting patients first and figuring out ways to streamline unnecessary administrative processes.”

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Back to the January 22, 2021 issue of ACP Advocate