CMS Proposes Rule to Enhance Prior Authorization Process

Centers for Medicare & Medicaid Services (CMS) is implementing a new rule to allow a more accessible healthcare authorization process as part of the Biden-Harris Administration by 2026. Its proceeding effort to improve America's current health data exchange will help American healthcare advance with its newly administered rules.

Health insurance is crucial anywhere in the world. It can protect you from unbelievably high medical costs that can easily surpass the cost of a home in America. As being sick is not something you plan, America's healthcare system must be easily accessible.

To expand health care access, more states are providing health care coverage to immigrant children. Since January 2022, the state of Connecticut and New Jersey joined the existing nine states and Washington D.C. to allow children without any permanent or legal statuses to register in either Medicaid or Children's Health Insurance Program (CHIP.)

“They are kids living in Maine and going to school in Maine and like their peers who were born in Maine or born in the U.S. or have citizenship status, they all have the same health needs,” said Maine State Senator Anne Carney. “And there is no policy reason to differentiate between two kids sitting next to each other in school.”

Health insurance can provide numerous services, including vaccines, shots, screening tests, and more. Health insurance plans also cover emergencies, surgery hospitalizations, pregnancy and birth, and even mental health services.

However, utilizing health insurance in America can often be time-consuming and energy-draining. To quicken the process and ameliorate the health insurance system, CMS is directing a new electronic prior authorization system by 2026.

CMS and its new electronic prior authorization systems

Centers for Medicare & Medicaid Services, or CMS, says its new rule will consolidate interaction within health insurance. The Biden-Harris Administration is to engage strongly with Medicare to simplify enrollment policies to broaden healthcare coverage. With the new rule and its methodical process, the study estimates that hospital and medical practices could save over $15 billion over 10 years.

“The Biden-Harris Administration has made it clear: we are committed to doing all we can to strengthen Medicare,” said HHS Secretary Xavier Becerra.

The new system is mainly for Medicare Advantage organizations, Medicaid and Children's Health Insurance Program organizations, Medicaid managed care plans, and qualified health plan insurers on specific facilities.

Per the new rule, there would be specific changes happening including an electronic prior authorization procedure for hospitals within the Medicare Promoting Interoperability Program and Merit-based Incentive Payment System clinicians.

What does the new rule entail?

“Today, we’re making it easier to enroll, expanding access, and eliminating delays in coverage to improve Medicare for the millions of Americans who depend on it. We’re working tirelessly to deliver the health insurance and peace of mind that enrollees deserve.”

It will also require a definite reason when refusing requests, and send over decisions within 72 hours for urgent requests and seven days for standard appeals. To advance health data, the new rule would allow current patient access API to contain prior authorization determinations.

They will also necessitate trading patient data utilizing Payer-to-Payer FHIR API if a patient is to ever switch from one to another practice.

CMS's modernization of America's existing healthcare insurance system will allow players to execute a prior electronic authorization process, which will abridge the time needed for certain payers to respond to authorization appeals. The new system will make the authorization process much more structured and simple.

The proposed rule will escort five new information requests, including social risk factor details, an electronic trade of behavioral health information among health providers, enhancing the trade of health documentation between certain providers in the Medicare Fee-for-Service program, advancing the Trusted Exchange Framework and Common Agreement (TEFCA), and the role interaction in improving maternal health results.

“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” shared CMS Administrator Chiquita Brooks-LaSure.

“The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers – helping us to address avoidable delays in patient care and achieve better health outcomes for all.”

CMS is working to nourish patient access to healthcare and allow a simple administrative system to allow clinicians to focus only on patient care.


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