Medicine & Health

Hospitals urge CMS to move ahead with Trump-era prior authorization rule

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The American Hospital Association is urging the Health and Human Services Department to revise and reissue a prior authorization rule proposed in the final days of the Trump administration.

The rule in question would streamline the documentation process, reduce the amount of time some insurers have to respond to prior authorization requests and require they build programs to receive those requests.

But the Biden administration froze implementation of the rule and others proposed by the previous administration and hasn’t indicated yet if it will move forward with the proposal.

In a letter to Chiquita Brooks-LaSure, administrator of the Centers for Medicare and Medicaid Services, AHA President Stacey Hughes urged the agency to finalize the rule with some changes, citing “administrative and clinical difficulties caused by inefficient prior authorization processes.”

Under the rule, Medicaid and CHIP fee-for-service and managed care plans and entities would have to respond to prior authorization requests within no later than 72 hours of receiving a request for expedited decisions and no more than seven days for standard decisions.

AHA argued the rule should be revised to require prior authorization responses within 72 hours for standard services and within 24 hours for urgent services.

The proposed rule also excludes Medicare Advantage plans from the changes, which Hughes said is “extremely troubling” and would “significantly reduce the potential impact of the regulation.”

About one-third of Medicare beneficiaries are in MA plans. Currently, MA plans can take up to 14 days to respond to a prior authorization request.

“In order to promote procedural improvements and prevent negative health outcomes associated with delays in care for all beneficiaries, we urge CMS to require MAOs to adhere to the requirements set forth in this proposal,” Hughes wrote. “Including them also would reduce administrative burdens and costs as providers would have less variation among health plans.”

Hughes also urged CMS to require MA plans “consider a service authorized” when a provider has a history of prior authorization approval of 90% or greater.

Insurers blasted the rule when the Trump administration proposed it in December, with America’s Health Insurance Plans President and CEO Matt Eyles mainly taking issue with the technology requirements.

Congress has also shown interest in the issue, with groups of bipartisan senators and House members introducing bills that would streamline prior authorization in MA plans.

The Senate bill, sponsored by Sens. Roger Marshall (R-Kan.), Krysten Sinema (D-Ariz.) and John Thune (R-S.D.), would require Medicare Advantage plans establish electronic prior authorization programs and issue real-time decisions for services that routinely get approved.


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