Payers concerned with uneven burden they face implementing new prior authorization rule

EHR data sharing
Payer groups were concerned that providers aren't shouldering enough of the burden to install new technology aimed at streamlining prior authorization. (Getty/andrei_r)

Payers are concerned they are shouldering too much of the burden to implement a new rule aimed at streamlining prior authorization and data sharing.

Several insurer groups were concerned about various aspects of a proposed rule released last month that requires Medicaid managed care, Children’s Health Insurance Program and federal exchange plans to build application programming interfaces (APIs) by Jan. 1, 2022 to exchange data with other payers and to streamline prior authorization.

But America’s Health Insurance Providers, the top insurance lobbying group, was concerned that the Centers for Medicare & Medicaid Services is requiring payers to set up these APIs but doesn’t give any “obligation no providers to connect them.”

“To achieve widespread industry utilization of standards and maximize the benefits of a streamlined process, technology adoption by all involved stakeholders—including providers, payers, and EHR vendors—is essential,” the group said in comments.

CMS needs to install incentives to promote provider adoption of electronic prior authorization, AHIP said.

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CMS and the Office of the National Coordinator for Health IT should also create specific requirements for EHR vendors to include the API functions in their technology as part of the Certified Electronic Health Record Technology program, according to AHIP. Providers should also have incentives in the Merit-Based Incentive Payment System and information blocking regulations.

Major EHR vendor Cerner commented that CMS needs to work with ONC on a certification program for API interoperability.

“CMS should consider if certification does play a role for the support of its proposals in this rulemaking which could enable certification of [health IT] appropriate for payer use,” Cerner said.

CMS estimates that the rule could cost taxpayers up to $2.8 billion over the next decade before accounting for any savings.

But CMS isn’t accounting for payers having to implement other rules on interoperability and price transparency, AHIP said.

“We are concerned that this estimate may not fully account for the costs associated with implementing this rule at the same time as the other referenced rules, at the tail end of the pandemic, and during what will surely be a tumultuous economic recovery,” AHIP said.

AHIP also wanted to change or at least stagger the implementation dates, which under the proposed rule is Jan. 1, 2023. The implementation dates should start no sooner than Jan. 1, 2024 and create an exception process for all impacted payers.

Other payer groups were worried about data sharing among different plans.

America’s Community Health Plans, which represent safety net plans, was concerned in comments that “peer-to-peer exchanges assumes a trusted relationship that generally does not exist.”

“Our member plans remain concerned that some of the information the proposed rule anticipates being shared with other payers will be used against our member plans for competitive reasons,” ACHP said. “Payers should not be required to expose proprietary information or trade secrets.”

Provider groups were largely happy with the rule, which they say targets a massive source of administrative burden. In addition to the API requirement, the rule calls for payers to make a decision on a prior authorization request within 72 hours for urgent requests and seven days for a standard request.

“The proposed rule is a welcome step toward helping clinicians focus their limited time on patient care rather than paperwork,” said the American Hospital Association in comments.

But AHA was frustrated that the rule excludes Medicare Advantage plans from the rule. Many of these plans have implemented “abusive prior authorization processes,” AHA said.

AHA also wanted to tighten the timeframes for when a payer has to submit a decision on a prior authorization request. The group wants responses for standard services within 72 hours and 24 hours for any urgent requests.

“Patients should not be forced to wait to receive care for longer than is necessary,” AHA said.

It remains unclear if CMS will finalize the rule before the end of the Trump administration on Jan. 20. Both payers and providers were livid that the agency only gave 17 days to comment on the rule, including during the holiday season, as opposed to the normal 30 days.