The prior authorization process has long been a thorn in the proverbial side of healthcare. Providers, payers, and patients (perhaps most of all) have come to regard this typically paper-based administrative process as onerous in a multitude of ways. It’s no secret that determining the necessity of a PA, identifying necessary clinical information needed, and then submitting and waiting on a determination has created delays in care and increased health care costs, administrative burdens, and physician burnout.
Thankfully, CMS has proposed a rule that will, when finalized, “improve the electronic exchange of health care data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients.” Building on the CMS Interoperability and Patient Access API rule published in 2020, this burden-reduction rule was initially proposed in December 2020 with a brief public commentary period; followed by federal review, finalization, and announcement of a final rule in January 2022. Shortly after the announcement and prior to the final rule being published in the federal register, the rule was pulled back. While a final, approved version has yet to be re-released, stakeholders should be getting out ahead of the rule release and implementing automated prior authorization processes via the standards called for in the final rule. Doing so will provide strategic and operational advantages for early adopters.
A Quick Rule Recap
At 347 pages, the proposed rule, “Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information,” in the most compact nutshell, contains four proposals that pertain directly to prior authorization.
Patient Access APIs: Payers must, as part of the already established Patient Access API, include data about pending and active PA decisions so that patient's real-time information on the status of the PA process and access to the requested care or service. Payers would also be required to report patient API utilization metrics and ensure that any third-party developers they work with adhere to applicable data-retrieval privacy policies.
Provider Access APIs: Payers would be required to develop and manage a provider access API so that payers and providers could share claims and encounter data and pending and active PA decisions for individual and groups of patients. This would augment the data sharing between the two major stakeholders in the prior authorization request and determination process.
Documentation and PA Burden Reduction Through APIs: Payers would be required to develop and maintain FHIR-enabled, workflow-friendly APIs for PA support, and document requirement lookup within EHRs. These APIs would, in turn, help payers meet proposed PA determination timeframe requirements - up to 72 hours for urgent requests and seven days for routine requests. This requirement would also assist payers in analyzing and compiling metrics around percent of PA requests approved, denied, approved after appeal, etc. for improved transparency.
Payer-to-Payer Data Exchange on FHIR: Payers would be required to exchange data using a FHIR-based API, and to do so at a patient’s request, whether that be during open enrollment or some other time of insurance policy transition. CMS also hopes that easier data exchange between a patient’s current and former payer will potentially eliminate the need for repeat PA processes.
Payers Should Prepare Now
Though there’s no guarantee that the coming months will see the burden-reduction rule reissued in exactly it’s previous form, however, payers shouldn’t waste any time in preparing to comply with its suggested requirements. Begin by determining whether your organization will develop the necessary software and workflows internally or partner with a vendor, keeping in mind that some may not yet have the necessary technical capabilities in place to develop software that meets the proposed requirements.
Next, think through how your organization will organize and codify its medical policies and clinical guidelines so that they also are in line with the proposed requirements. Will care area, cost, or volume take precedence as your organization begins to adjust its PA strategy?
Consider taking advantage of existing resources as your organization and its technology partners begin looking at how best to tackle PA overhauls. FHIR-focused accelerators like the HL7 DaVinci Project and CodeX offer FHIR implementation guides and other forms of expertise that can help ensure compliance. FHIR Connectathons, which feature hands-on API development and testing, may also prove beneficial, as they offer opportunities to test the capabilities of existing solutions and exposure to what other organizations are doing.
Physicians should be communicating and collaborating with their EHR partners ensuring their administrative and clinical workflow and the data captured in these processes converge and flow through to support the access, use and exchange of applicable information to support automated PA via the FHIR standards (Da Vinci CRD, DTR, PAS) called for in the proposed rule.
New Processes Now Will Help Avoid Workarounds Later
While CMS hasn’t set any deadlines in stone, it would be prudent of payers and providers to begin preparing for the requirements set forth in the proposed burden-reduction rule. The days of paper-based PA processes are slowly but surely coming to a close, as automated health IT processes become more ubiquitous, and public and private organizations become more vocal about the need to eliminate administrative burdens that hasten physician burnout and create costly barriers to care. According to CMS, once finalized, the rule will save between $1 billion and $5 billion over the next 10 years. No healthcare stakeholder wants to be caught flat-footed by a federal requirement they weren’t quite prepared for. Patient care hangs in the balance, after all. Developing new FHIR-enabled, API-based PA workflows now will ensure your organization is prepared to not only comply with future CMS rules but will enable cost reduction, operational efficiency and expedited access for patients needed care.
If your organization needs support in how to best approach planning for the re-emergence of the PA Burden Reduction Rule or just to better understand the proposed policy and the technology and standards available for use, please reach out to me at kim.boyd@pocp.com
