In a strongly worded letter that includes specific examples of how prior authorization requirements harm patient care, the American Hospital Association has urged CMS to expeditiously finalize its Advancing Interoperability and Improving Prior Authorization Processes proposed rule.  The proposed rule would generally apply to Medicare Advantage plans, state Medicaid and CHIP plans, and plans purchased on the federal exchanges and was originally published on December 6, 2022.

The letter, sent on October 27, 2023 to CMS Administrator Chiquita Brooks-LaSure, stated that the prior authorization process is used too often by health plans “in a manner that leads to dangerous delays in treatment, clinician burnout and waste in the health care system.”

The AHA letter highlighted several problems with the prior authorization process driving the need for prior authorization reform.

First, prior authorization policies lead to delay in patient care. Showing the magnitude of this problem, the letter pointed to an American Medical Association survey in which 94% of physicians reported delays in patient care associated with prior authorization requests and 33% of physicians reported that delays due to prior authorization had led to a serious adverse event for a patient in their care.

Second, prior authorization policies burden providers and divert valuable resources from patient care. This issue was highlighted in a recent AHA member survey that found that 95% of hospitals and health systems reported an increase in staff time spent seeking prior authorizations from health plans in the past year.  The letter gave a specific example and pointed out that these “burdens come at a time when the health care system already is struggling with workforce shortages with wide-ranging consequences for access to care.”

Third, lack of transparency in health plan prior authorization policies and required documentation leads to improper delays and denials of provider claims. Fourth, there is wide variation in health plan submission processes, requiring a significant amount of staff time to navigate.

In urging CMS to promptly finalize the proposed Advancing Interoperability and Improving Prior Authorization Processes rule, AHA concluded by stating:

In light of these burdensome realities, the AHA strongly supports prior authorization reform, including adoption of electronic prior authorization processes that have the ability to streamline the arduous process to improve patient care and reduce provider burnout. We applaud CMS for taking these important steps to require plans to implement these critical prior authorization and electronic data exchange reforms.

 (bolding in the original)

A copy of AHA’s October 27, 2023 letter is linked here.  CMS’s Fact Sheet regarding the proposed rule is linked here.

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