The future remains uncertain for a Trump Administration rule which among several things will streamline “prior authorization” for health insurance coverage.
On January 15, 2021, the Centers for Medicare & Medicaid Services (CMS) released the final rule but on January 20, 2021, the incoming Biden White House issued a memorandum freezing any last-minute regulations finalized by the Trump Administration. “This matter is currently under CMS review and we look forward to sharing additional information about this program soon,” said a CMS agency spokesperson.
Prior authorization is a big factor in health care says Robert F. Graboyes, a senior research fellow with the Mercatus Center at George Mason University. “This is the mechanism by which insurers review the treatment plan of the provider (which can range from new medications to surgical procedures) and decide whether or not to pay on behalf of the patient. While the idea of prior authorization is eminently reasonable, in practice, it is a source of needless delay, uncertainty, and pain,” Grayboyes told Health Care News.
A common complaint with prior authorization is that it takes away too much time from patients and health insurance plans are becoming increasingly dependent on it.
A related issue that the finalized rule addressed was the current state of electronic health records (EHRs). EHRs are intended to document a patient’s medical history and health care over time that should, ideally, be easily shared across providers. Unfortunately, health care lags in its effective use of technology and application programming interfaces (API). Frequently providers do not have access to a patient’s data, and if they do the data is not effectively integrated from different providers.
“Systems should be flexible enough to incorporate future, not-yet-imagined types of health care data,” said Graboyes.
As finalized, the rule required payers in certain government programs like Medicaid and the Children’s Health Insurance Program (CHIP) to build application programming interfaces (API) for data exchange and prior authorization.
Too Many Faxes
Prior authorization is a major administrative burden for both patients and providers, especially because it relies on outdated technology, the fax machine. A 2018 Council for Affordable Quality Healthcare report says that 88 percent of prior authorizations are handled by telephone or fax machine. If reimbursement for some patients is initially rejected, appeals may take weeks.
While health care technology can improve, the systems and insurers are resistant to change, says Grayboyes. “Insurers have made the process increasingly slow and onerous, creating a sort of war of attrition on paying for anything—even the most reasonable and common of services—in a timely fashion. The problem could be eased by a system of efficient electronic health records (EHRs), but federal government rules have assured that EHRs remain clunky, inefficient, and the bane of providers.”
Another important part of the finalized rule is the timing requirement. Under the rule as finalized by the Trump Administration, plans must reduce decision timelines for prior authorization. Specifically, payers would have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests.
This change alleviates the burden on certain patients, including those suffering from mental illness. “This is not just a problem of finance and convenience. The hold-ups can inflict pain and even cost lives. Psychiatry is often hardest hit, with those suffering from mental illness or addiction often least able to navigate the delays in receiving medications or drug rehabilitation treatments,” said Graboyes.
Bureaucracy v. Patient Care
The slow change in EHRs and prior authorization continues to hamper medical providers’ ability to provide care. The paperwork process that providers must go through, even to provide seemingly simple things like blood pressure medication, is onerous.
“The administrative burden often placed on providers goes uncompensated, so a doctor thinks twice before prescribing the best drug for a patient—knowing the prescription will be hung up in reams of forms and lengthy phone calls with a recalcitrant insurer,” said Graboyes.
Despite the Biden Administration’s delay of the rule, regulators need to address the inefficient system of EHRs and rules for prior authorization. “A better system of EHRs, combined with more sensible rules for prior authorization, could be a win for patients, providers, and perhaps even insurers, with faster treatment, better treatment, and perhaps even improved costs,” said Graboyes.
Kelsey Hackem, J.D. (firstname.lastname@example.org) writes from the state of Washington.
Robert Graboyes, Darcy Bryan, M.D., “Simplicity, Interoperability, Symmetry, and Privacy are All Important Goals for New Health Care Information Rules,” Mercatus Center, George Mason University, January 4, 2021: https://www.mercatus.org/publications/healthcare/simplicity-interoperability-symmetry-and-privacy-are-all-important-goals-new