ONC, CMS officials plot next reforms to entice adoption of electronic prior authorization

WASHINGTON, D.C.—The Biden administration is exploring requiring new certifications for provider electronic health records to help facilitate electronic prior authorization, a major source of administrative burden, officials said. 

A certification requirement for providers is one of the regulatory avenues the Office of the National Coordinator for Health IT is considering, according to ONC Director Micky Tripathi during the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum in Washington, D.C., on Wednesday. The goal is to ensure that there is something to communicate with payers who are staring down new requirements for electronic prior authorization. 

“It feels like there is a lot of interest in having certification kinds of requirements in EHRs,” Tripathi said, referring to comments made to a request for information issued by ONC last year. 

He added that ONC is working with the Centers for Medicare & Medicaid Services to synchronize any new requirements for electronic prior authorization. CMS released a proposed rule late last year that mandates federal health plans, such as Medicare Advantage and Affordable Care Act plans, implement an electronic prior authorization system by 2026. 

It includes incentives for hospitals and physicians to also adopt an electronic system, which is intended to help curb a process that a recent survey of physicians called a massive source of administrative burden and burnout.

Insurers rely on prior authorization as a cost containment tool. It requires physicians to get insurer clearance for certain items and services, but the use of the tool has skyrocketed among plans. 

While some insurers have endorsed the concept of electronic prior authorization, AHIP has called for CMS to do more to ensure adoption among providers. The goal is to ensure that the work to set up by a payer for an electronic system can be used by the provider.

Tripathi said he understands that there needs to be interoperability between payers and providers on this issue. 

“You could have a payer requirement but if there is nothing standardized on the provider side well that makes it really hard to scale … and how much does that accomplish from a market perspective,” he said. “We are taking a look at that.”

Another area of contention among insurers is the need for a national provider director. 

“If payers must electronically share data with one another and providers, a national directory containing each organization’s digital endpoint is key,” according to AHIP’s comment letter to CMS on the proposed rule. 

CMS did ask for information on how to create a national directory, but one official acknowledged Wednesday that it will be a difficult endeavor. 

“Overwhelmingly stakeholders were supporting a national directory if done right,” said Alexandra Mugge, director and deputy chief health informatics officer for CMS, during the session. “That is a really big if.”

She said that right now CMS maintains numerous provider directors but also has databases on health plan information. The issue though is maintaining accuracy when you combine that work. 

“I think we can get to the point where a national director of healthcare has the potential to change healthcare moving forward,” Mugge said.