CMS proposes rule streamlining prior authorizations 

Posted on: 1/8/21

The Centers for Medicare & Medicaid Services (CMS) has proposed a rule to remove inappropriate barriers to patient care by streamlining the prior authorization processes for the impacted health plans. While prior authorization can be a helpful tool for ensuring patients receive appropriate care, the practice is too often used in a manner that leads to dangerous delays in treatment, clinician burnout, and more waste in the health care system. The proposed rule is a welcome step toward helping clinicians focus their limited time on patient care rather than paperwork. 

In the proposal, CMS places new requirements on Medicaid and Children’s Health Insurance Program (CHIP) managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plan (QHP) issuers on the Federally-Facilitated Exchanges (FFEs), while also indicating that Medicare fee-for-service will be adhering to the requirements. CMS proposes to require Medicaid and CHIP plans to deliver prior authorization decisions of health services in no later than seven calendar days after the date of the receipt of the request for a standard determination and 72 hours following the receipt of the request for an expedited determination.  

However, CMS has excluded Medicare Advantage (MA) plans. OHA identified barriers to discharge patients back in an October 2020 document that was presented to state leadership. Prior authorization approval timelines for post-acute care were identified as an area of concern. OHA had conversations with the governor’s staff; Kevin Corbett, secretary of health and mental health and CEO of the OHCA, CMS regional office, and AHA on this issue. Unfortunately, the recent determination is that relaxing pre-authorizations does not apply to Medicare Advantage plans. By excluding the MA plans, Oklahoma hospitals will still have to continue to wade through the difficult and time-consuming prior authorization processes these plans already have in place.  

For more information, click here. (Mitzi McCullock)