New CMS Rule Designed to Streamline Prior Authorization and Patient Data

The new CMS rule is designed to advance patient data exchange, interoperability, and clinical systems by streamlining prior authorization.

A recent proposal from The Centers for Medicare & Medicaid Services (CMS) would implement a new rule which is aimed to streamline prior authorization and patient data exchange in order to lighten clinician workload.

The rule would give room for providers to spend more time with patients and advance patient health care.

Prior authorization is an applied management strategy that healthcare payers use to ensure the best and most cost effective medication available to patients.

When a medication has a prior authorization requirement, a provider needs to submit specific documents to the healthcare payer in order to have permission to prescribe the drug.

Prior authorization requirements are demanding and lead to delays in providing care, with 60 percent of requests being made by phone and 46 percent by fax. A few are made electronically.

Seema Verma, administrator of CMS noted that prior authorization is a tool for payors to ensure program confidence, but that there is a better way to make the process work more efficiently.

The proposal would build on the CMS interoperability rule by growing interoperability and increasing accessibility to patient data. Efficient patient data exchange and better interoperability can even help mitigate the increased spread of the coronavirus.

The new rule would usher in a new era of lower costs and higher quality care according to Verma. Payors and providers would have access to complete patient histories, allowing for more seamless patient care by reducing unneeded procedures.

Each element of this proposed rule would play a key role in reducing the administrative weight on frontline providers while at the same time improving patient access to the best health care information possible.

According to CMS the proposal would mean that programs like CHIP, Medicaid and QHP would be required to develop application programming interfaces (APIs). These interfaces would be programmed to back prior authorization and data exchange.

The Office of the National Coordinator (ONC) for Health Information Technology has proposed adopting the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to accommodate the interoperability rule.

Verma continued by saying that prior authorizations are a leading cause of provider burnout and that it is a burden that takes time away from patients’ treatment. If 25% of providers implemented these new electronic solutions then the proposed rule would save roughly 1 to 5 billion dollars over the next decade.

If the rule passes it would force payers to integrate an FHIR-sourced API to coordinate the patient data exchange. This would streamline service and give patients complete access to their medical history while also bringing this data from one payer to the next.

Providers, payers and patients would have more access to information including pending and past prior authorization decisions, which would lighten administrative duties, reduce costs for providers and improve patient care.

Verma concluded that for patients there would be no more tangling with past providers and hunting down ancient fax machines to have access to one’s own health information. Providers save time piecing together patient health histories based on incomplete data. For payers this is a first step in building an important data sharing structure that will add value to the entire healthcare system.


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