New Hospital Prior Authorization ChanNew Hospital Prior Authorizationes for 2022 Take Effect in 2023

Implemented from January 2023

2022 Updates to Hospital Prior Authorization Process Now in Place

In 2022, the healthcare industry saw several updates and developments aimed at streamlining the prior authorization process.

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The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that seeks to streamline the process and is expected to save hospitals and medical practices over $15 billion over a decade.

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Introduction

Other payers, such as Blue Cross Blue Shield of Massachusetts and Florida Blue, are implementing strategies to reform their prior authorization systems. The U.S. House of Representatives passed a bill to reform the Medicare Advantage prior authorization process, and the Governor of Michigan signed a bill that shortens the time insurers have to consider prior authorization requests and provides more information about the process.

The rule is expected to improve patient access to care, reduce administrative burdens for clinicians, and support interoperability in the healthcare system. There are several solutions to improve the prior authorization process, such as automation, outsourcing, and collaboration between providers and payers.

Overhauling the prior authorization process is reaching its peak in state legislatures with 40 states expected to discuss measures simplifying doctors' process of obtaining health plan approval for procedures, tests, and treatments.

Importance:Asthecountryrecoversfromthe pandemic,SurgeonGeneralVivekMurthy andothersattributephysicianandhealth workerburnouttoadministrativeburdens suchaspriorauthorization.

Bidenadministrationproposedregulationsin Decembertoestablishanelectronicsystem andreducewaittimesforpriorauthorization inMedicareAdvantage,Medicaidmanaged careandAffordableCareActexchange plans.

Behind the news

Doctorsandinsurershavebeeninaprolonged conflictoverpriorauthorizations,butphysiciansclaim ithasbecomeworseinrecentyearsleadingtodelays forpatients,includingthosewithstablechroniccond

According to a 2021 survey by the American Medical Association, a third of surveyed providers reported that prior authorization delays caused serious adverse events for one of their patients. The physician's organization is advocating for model legislation to apply to individual and small-market health insurance plans in state markets.

A November analysis by consultancy Crowe revealed that prior authorization denials for hospital inpatients caused a 67% increase in the dollar value of insurer coverage denial from January 2021 to August 2022.

Counter argument

Health insurers claim that prior authorizations eliminate waste, save money, and are essential to guarantee patients receive necessary care.

CMS has proposed requirements for Medicare Advantage (MA) organizations, state Medicaid and CHIP agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers. These requirements aim to promote consistency across coverage types and are estimated to save physician practices and hospitals over $15 billion over 10 years.

The proposed rule by CMS aims to improve patient access to care, reduce the burden on clinicians, and support interoperability across healthcare. It includes 5 requests for information on standards for social risk data, electronic exchange of behavioral health information, exchange of medical documentation, TEFCA, and maternal health outcomes. The proposed rule replaces the previous one from Dec 2020 and is open for public comments till March 13, 2023.

CMS seeks comments from patients, families, providers, advocates, professional associations, and underserved communities.