• CMS adopted a blanket rule to renew electronic preauthorization, a short month since it was first proposed, as the Trump administration scrambles to codify its health agenda ahead of President Joe Biden’s inauguration.
• The rule requires payers with Medicaid plans, the Children’s Health Insurance Program, and those who provide services on federal exchanges to use standard application programming interfaces to provide providers and patients with electronic access to information, prior authorization, even in decision processing. Additionally, payers must make quicker decisions about prior authorization requests.
• Insurers would see the biggest impact from the rule, prompting payers to pressure US health insurance plans as “a series of low promises,” “poorly drafted and hasty” and “timid” in a statement Friday to criticize.
Pre-approval, which requires a doctor to get the green light from a patient’s insurance company to receive medications or treatments before they are administered, has become popular with insurers to cut down on unnecessary or expensive treatments. Providers generally view the process as yet another administrative framework to follow, emphasizing that it is one of the most important factors contributing to physician burnout and potentially harmful patient care.
First proposed on December 10, the rule aims to streamline the process by improving electronic data sharing and building on the interoperability terms finalized by the Trump administration in March.
Although providers generally supported the rule when it was first proposed, insurers criticized it, calling the implementation plan too hasty, arguing that it would place an unnecessary burden on a healthcare system exposed to the pandemic and other regulatory changes.
Additionally, the comment period for the rule was extremely tight: After publication in the federal register, the industry had only 17 days to analyze the 100-page rule and write comments. Generally, the comment period is between 30 and 60 days.
This suggestion was clearly ignored by the office and codified just five days before Biden switched to a new health administration.
“CMS wants to ensure that the guidelines can be implemented in a timely manner so that they can have a positive impact on patients, providers, and payers,” a CMS spokesperson said when asked about the rapid change.
AHIP clearly disagrees.
“Much of today’s new CMS rule consists of a series of empty promises. This poorly designed and hastily constructed rule makes an aircraft take off before its wings are touched and forces health insurers to build these technologies. Lobby Matt Eyles.
“Miraculously, the administration was able to deliver the ‘critiques’ and ‘answers’ in less than nine working days, despite more than 250 stakeholders submitting thousands of pages of public comment, which was totally insufficient for The public is consistent with the thoughtful approach of warning and commentary to policymaking that is typically set for a rule estimated to be nearly $ 3 billion to implement, Eyles continued.
API regulations typically come into effect in 2023. Beginning in 2024, payors, with the exception of state health insurers, have a maximum of 72 hours to make pre-approval decisions for urgent claims and 7 calendar days for standard inquiries.
Medicare Advantage plans are not included in the final rule, but CMS is considering additional regulations to subject them to similar requirements.
This omission was a major hurdle for hospital groups, who argued that the exclusion of private plans, which cover about a third of Medicare beneficiaries, could result in greater variation in pre-approval processes in the United States. And reduce the incentives for suppliers to use the new standardized methodology.
“The significant exclusion from MAID plans is of great concern and significantly reduces the potential impact of regulation,” the American Hospital Association wrote in its comments on the proposed rule.