Friday, January 15, 2021

Very Brief Blog: PRIOR AUTH RULE; CMS Finalizes with Blazing Speed, Payers Rebel

Update - I think Biden deep-sixed this rule. Here.

Since they may now be collector's items, I put the press release and fact sheet and Prior Auth Final Rule in a cloud zip file - here.


CMS released a proposed rule in December regarding EHR and other requirements for Prior Authorization, and conducted an abbreviated comment period that riled some healthcare providers.   

Remarkably, on January 15, 2021, CMS released the final rule (in the inspection copy that precedes Federal Register publication).   This was lightning speed, usually several months (or more) follow after the close of a comment period (January 4).

The rule doesn't so much change the existence of prior authorization, which many providers wish would happen, as change the format and channels for prior authorization.  More advanced methods of electronic communication are required, with visibility in uniform formats to both patients and providers. 

See the CMS fact sheet here.   Press release here.  See the CMS inspection copy final rule here.

The Payer industry disliked the initial rule proposal, and has already pretty harshly slammed the rapidly prepared final rule as half baked and slapdash.  Here.  See also Healthcare Finance here. Medical Economics here.


I don't know if this rule will be delayed by the Biden administration or not.  Another rapidly appearing rule, appearing under the unusual mechanism of "interim final rule," on Part B drug pricing, has been under court injunctions to postpone implementation.  Here.  This is the "Most Favored Nation" (MFN) drug price rule that pegs US Medicare prices for drugs to European prices for drugs.

Proposed rule press, December 10, here.  The proposed rule press release states:

Today, under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve the electronic exchange of health care data among payers, providers, and patients, and streamline processes related to prior authorization to reduce burden on providers and patients.

In contrast, the January 15 press release on THE SAME RULE, deletes any mention of President Trump entirely.

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.


See my earlier blog: "After January 6 Disorder, CMS Stops Referring to President Trump's Leadership."


Interesting Update:

In a JAMA article on excess administrative costs in healthcare, Feb 2, 2021, 325:427, by Robert Kocher of USC, there is a discussion of Affordable Care Act Section 1104, which had a three-phase plan to reduce US administrative health costs.  Kocher mentions that Part III involved streamlining prior auth processes, but was never implemented.   This new Prior Auth rule from CMS appears to pick up the ball and run with it, but doesn't mention Section 1104 anywhere.


For a 2020 trade journal article on pro's and con's of prior auth, from a payer perspective, here.


AMA comments on the prior auth rule - here.