Biden Probably Won't Roll Back New Prior Authorization Proposal

by Leslie Small

Building on previously finalized regulations aimed at advancing data interoperability in health care, CMS on Dec. 10 proposed a new rule that would require certain health plans to make their prior authorization processes more efficient and share even more data with providers and patients.

If finalized, the rule would apply only to managed care Medicaid and CHIP plans, fee-for-service Medicaid and CHIP plans, and Qualified Health Plans (QHPs) on the federally facilitated exchanges.

"The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care," the American Hospital Association said in a statement, adding that "we are deeply disappointed, however, that CMS chose not to include Medicare Advantage plans."

The new proposal builds on an interoperability rule that CMS finalized in May. That rule requires Medicaid, CHIP, QHP and MA plans to share claims and other health information with patients through a Patient Access API, which will allow them to obtain their data through any third-party application they choose.

Under the new rule, starting Jan. 1, 2023, affected payers would have to include information in their already established Patient Access APIs about patients' pending and active prior authorization decisions.

The rule would also make several changes to streamline the prior authorization process itself. As a press release from CMS explained, Medicaid, CHIP and QHP payers would be required to build and implement APIs that "allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically."

Although the incoming Biden administration could opt to reverse some of the more controversial regulations issued by the Trump administration in recent weeks, Andrew Van Ostrand, a principal in Avalere Health's policy practice, says he doesn't expect this latest rule will be among them.

The official comment period for the rule closes on Jan. 4, so CMS is likely to be able to finalize it before President-elect Joe Biden's inauguration on Jan. 20, he says. "I also think that this larger issue of data interoperability…that’s been a bright spot from a bipartisan perspective."

Therefore, "I do expect a Biden administration to carry these initiatives forward and build on them," Van Ostrand says. However, he says there could be "tweaks to deadlines and tweaks to specific requirements."

From Health Plan Weekly