Posted December 10, 2022
By Diane Eastabrook, McKnights Home Care
Provider advocates are applauding a proposed rule by the Centers for Medicare & Medicaid Services that would speed up prior authorization of healthcare services by payers.
The proposal would require Medicare Advantage (MA) plans, Medicaid and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to streamline their prior authorization processes. Payers would be required to respond to urgent requests for healthcare services within 72 hours and standard requests within seven calendar days. They would also be required to include a specific reason when denying requests and publicly report certain prior authorization metrics.
“We are very pleased that CMS has recognized the value and importance of expediting prior authorizations in MA plans and Medicaid,” National Association for Home Care & Hospice President and CEO William Dombi told McKnight’s Home Care Daily Pulse on Wednesday. “Patient needs warrant quick and accurate decisions by payers.”
The proposal also includes other administrative guardrails, including a requirement that certain payers implement standards that would allow patient data be exchanged seamlessly between payers when a patient switches coverage or when they have concurrent coverage.
CMS Administrator Chiquita Brooks-LaSure said the goal of the rule is to “improve the care experience across providers, patients and caregivers — helping us to address avoidable delays in patient care and achieve better health outcomes for all.”
CMS will accept public comment for the proposed rule through March 13, 2023.
The agency isn’t the only group in Washington taking aim at prior authorization by payers, especially among MA plans. Legislation that would require MA plans to streamline the process sailed through the House last September and is pending before the Senate.
MA plans have also come under fire from government watchdog Office of Inspector General for denying and delaying services to older adults covered under those plans.
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