Brief Blog: HHS Proposes Widespread "Electronic Prior Authorization" by 2026

 In a new rulemaking proposal on December 6, 2022, CMS proposed to broadly require electronic versions of prior authorization by 2026.   The proposal will impact ACA Exchange Plans, Managed Medicaid, and Medicare Advantage.  

That makes the regulatory proposal much broader than 2022's Hill proposal, the "Improving Seniors' Access to Care Act," which pointed to Medicare Advantage plans (FN1).   Reducing the burdens of prior authorization has been an AMA priority, and also heavily impacts some diagnostic tests, including imaging and genomics.  

For a 2019 review of Lab Benefit Managers by Phillips and Deverka, here.  A 2020 6-page white paper on LBM by Kentmore consultancy, here.  A 2022 article comparing PBM and LBM, here.  Articles on radiology benefit management, RBM, go back 15 years or more (e.g. here). 

• On the new HHS Prior Auth proposal, trade journal article in Fierce Healthcare here.  
• And Healthcare Finance here.  
• And Health Payor Intelligence here.
• Healthcare Dive here. Update with more interviews, here.
• Find a 403-page pre publication  document at Federal Register here.  
• The typeset version will publish December 13.
• CMS also issued a lengthy fact sheet summarizing the proposed rule - here.

The new proposal also withdraws aspects of a late Trump proposal in December 2020 (85 FR 82586).  (2020 press release here.)

December 6, 2022

Also of possible interests to labs and imaging centers, the rules propose to facilitate (within Medicare) exchange of information between ordering providers and rendering providers/suppliers.

The rule has a 90 day comment period (circa March 6, 2023).  

Sample text from 12/6 fact sheet:

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FN1

The point of this article is new CMS rulemaking that affects health plans widely, from Medicare Advantage to ACA Exchange.   This contrasts to a Congressional bill cited above, that addressed only Medicare Advantage.

On the general topic of Medicare Advantage denials (and it's denials, not approvals, that rankle providers), there was a January 2022 Health Affairs article about MA denial rates (entry point here). What I highlighted in my blog then, and what was kind of lost in the article, most of the denials were for lab tests.    The OIG weighed in on MA denial rates in an April 2022 report (entry point here.)  Finally, on a somewhat nerdy policy point, MA plans aren't subject to lots of rules that apply to FFS Medicare.  For example, there's a big policy apparatus around AUC/Appropriate Use Criteria in Imaging, dating back to PAMA 2014 and slowly implemented.  All those rules apply to FFS Medicare, not MA plans.  (Entry point here).   Similarly, there's a big fuss every year about new tech add-ons to DRGs, but those formally apply to the half of patients in FFS Medicare, not the half in MA.