Health insurance pre-authorization rule recommended by CMS

The Centers for Medicare and Medicaid Services aims to overhaul pre-authorization health insurance under the proposed rule announced Tuesday.

The regulation would require exchange, Medicaid, and Medicare Advantage providers to ease their pre-authorization processes and respond to “urgent” requests within 72 hours and requests standard within seven days. According to CMS, this will halve the time it takes for Medicare Advantage plans now to respond to clinicians’ prior authorization requirements.

Insurers will have to justify refusing and publicly reporting data about pre-authorization decision. Insurers and providers may also be required to implement technology that allows a patient’s health information to pass from one payer to another so that medical records are available when the policyholder buys insurance. Change insurance company.

“The interoperability and pre-authorization proposals we announce today will streamline the pre-authorization process and accelerate healthcare data sharing to improve the care experience among providers. providers, patients, and carers—helping us address avoidable delays in patient care and achieve better health outcomes for all,” CMS Administrator Chiquita Brooks- LaSure said in a press release.

CMS estimates the proposed rule will save suppliers more than $15 billion over 10 years.

“The AHA commends CMS for taking important steps to remove inappropriate barriers to entry,” said Ashley Thompson, senior vice president of the American Hospital Association for public policy analysis and development. with patient care by streamlining the pre-authorization process for some health plans. release. “Prior authorization is often used in a way that leads to dangerous delays in patient care, burdens healthcare providers, and adds unnecessary costs to the system.” health care.”

This rule will add interoperability measures to the quality metrics by which providers are evaluated under the Performance-Based Incentive Payment System and hospital quality programs.

“Americans should have clear, concise, and customized information with streamlined processes to improve health care quality, affordability, and accessibility. Insurance providers. healthcare is committed to providing them, and we look forward to continuing to work with the authorities on these important issues,” said Matt Eyles, CEO of the health insurance trade group AHIP, in a statement. a press release.

The The House of Representatives passed the Aging Access to Timely Care Act in September, this would require Medicare Advantage providers to apply the same standards. Supporters hope the bipartisan bill — backed by health insurance and provider groups — will be passed by the Senate in a post-election session this month.

“We’re pleased with HHS’s proposed rule to streamline pre-authorization processes, but comprehensive reform is needed to reduce pre-authorization volumes and ensure patients receive timely care.” President of the American Academy of Family Physicians, Dr. Tochi Iroku-Malize said in a news release. “This regulation is good news for GPs and is an important first step in reducing the burden and improving access to care. We continue to urge the Senate to pass it quickly. The Elderly Access to Timely Care Improvement Act.”

The proposed rule is expected to be officially published in the Federal Register on December 13.


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