CMS proposes reforms to standardize Prior Authorization

CMS has proposed the following five key provisions to improve prior authorization:

• Patient Access API: This would require impacted payers to include information about patients’ prior authorization decisions in the Patient Access API, which is a secure and standardized way for patients to access their health information through third-party applications. This would help patients better understand their payer’s prior authorization process and its impact on their care. This would also require impacted payers to report annual metrics to CMS about patient use of the Patient Access API.
• Provider Access API: This would require impacted payers to build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship. This would include patient claims and encounter data, data elements identified in the USCDI version 1, and prior authorization requests and decisions. This would enable better coordination of care and support value-based payment models. This would also require payers to provide a mechanism for patients to opt out of making their data available to providers through this API.
• Promoting Interoperability Program and MIPS: This would introduce a new measure for eligible hospitals and CAHs, under the Medicare Promoting Interoperability Program, and for MIPS eligible clinicians, under the Promoting Interoperability performance category of MIPS. The measure would assess the use of electronic prior authorization processes by providers and incentivize them to adopt the new APIs.
• Payer-to-Payer Data Exchange: This would require impacted payers to exchange certain patient data at the patient’s request when a patient transitions to a new payer. This would include USCDI version 1 data, claims and encounter data (excluding cost information), and prior authorization requests and decisions. This would facilitate continuity of care and reduce burden on patients and providers.
• Documentation Requirements: This would require impacted payers to publicly disclose their prior authorization criteria, statistics, and practices on their websites. This would increase transparency and accountability for payers and help providers and patients understand the prior authorization process.