The Centers for Medicare & Medicaid Services (CMS) recently proposed a new rule to advance interoperability and improve the prior authorization (PA) process for Medicare and Medicaid patients. Specifically, the rule stipulates that health plans adopt electronic prior authorization processes, adhere to shorter turnaround times, clearly communicate denial reasons, publish key metrics annually, and implement the Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface (API). The intent of CMS’s rule is to improve transparency, reduce physician burden, and accelerate patient access to care.
This follows closely on the heels of last year’s legislation, the Improving Seniors’ Timely Access to Care Act, which unanimously passed the House in September, but did not make it to the Senate floor before this year’s Congress convened. The new rule from CMS represents additional progress and includes public feedback from a former iteration of the rule that was proposed in December 2020. Generally viewed as a highly burdensome process, PA is considered necessary by health plans to help ensure their members receive safe, quality, high-value care; however, the process consistently leads to friction with physicians and delays in care for patients.
Historically, efforts to remedy the PA process have focused on automating health plans’ existing processes – as if efficiency was the only missing ingredient in an otherwise sound process. The rule, while designed to help drive greater PA efficiency and transparency, sets a foundation for payers to do much more – including reducing unwarranted care variations and better aligning with value-based care models to more holistic, longitudinal care and driving evidence-based care paths – all of which can lead to better, faster care.
It’s true that PA is time-consuming and fraught with administrative burdens for physicians and staff – typically requiring faxing and even the mailing of clinical notes. On the health plan side, some employ large call centers to reduce the administrative burden on their staff. A recent AMA survey revealed that physicians and their staff spend an average of 13 hours each week completing PA requests. The survey also found that 93% of physicians say that PA delays patients’ access to necessary medical care, and 82% of physicians report that PA processes can sometimes lead to treatment abandonment.
Indeed, digitizing PA processes, for example by employing the FHIR API, does accelerate the submission of requests and the ensuing clinical review process. It does not, however, on its own, transform PA into a more valuable tool for care management or for reducing unnecessary variations in care. So, a valuable opportunity for health plans to further improve either quality of care is overlooked.
While the provisions for the CMS rule would not go into effect until 2026, health plans using manual or partially automated PA processes will need to invest in infrastructure and technology to support this transition well before then. This pivotal moment provides an opportunity for health plans to adopt advanced technologies that not only ensure regulatory compliance but enable more strategic care management. It is time for intelligent utilization management, beginning with prior authorization.
Using artificial intelligence and machine learning, an intelligent prior authorization platform can extract patient-specific data from several sources, including the electronic health record. Armed with the patient’s care history and evidence-based criteria, an intelligent platform can guide physicians toward care choices that are likely to improve patient outcomes. And rather than submitting several disconnected PA requests for one patient, clinicians can get multiple services approved simultaneously – spanning an entire episode and effectively speeding patient access to the most appropriate care.
An intelligent prior authorization platform can easily meet the rule’s requirements for greater automation, more transparency, clearer guidance, and accelerated approvals by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians.
The sole focus of prior authorization should be the patient – better outcomes, better patient experience, and a more clinically appropriate care path. Electronic PA is surely a good starting point, but it is not enough. To have a significant impact on the cost and quality of care, healthcare should adopt intelligent technology that gives providers meaningful support to help achieve the fastest and best possible outcomes for patients.
About Alina M. Czekai, MPH
Alina M. Czekai, MPH, is the Vice President of Strategic Partnerships at Cohere Health, a collaborative utilization management technology vendor. Prior to joining Cohere, she was a senior advisor to Administrator Seema Verma at the Centers for Medicare & Medicaid Services. LinkedIn – https://www.linkedin.com/in/alinaczekai/.
