ACR Recommends Changes to Prior Authorization Proposed Rule

The American College of Rheumatology (ACR) commended CMS for its proposed prior authorization policies but asked the agency to expand its guidance to other utilization management tools and shorten the prior authorization decision timeline.

Prior authorization processes have caused patient care delays and created unnecessary administrative burden for providers. Care delays can be especially dangerous for patients with rheumatic diseases, as timely care is critical for suppressing severe inflammatory conditions and keeping diseases in remission, ACR noted in its letter to CMS Administrator Chiquita Brooks-LaSure.

While ACR supported the goal of the Advancing Interoperability and Improving Prior Authorization Processes proposed rule to streamline the process, the group offered several suggestions on how CMS can improve the rule.

The letter requested that CMS expand prior authorization guidance beyond medical services and include policies for all utilization management tools for services and therapeutics, including step therapy policies.

According to ACR, step therapy can prevent rheumatology patients from receiving necessary medications on time.

“While we recognize the need to ensure services and treatments are medically appropriate to cut wasteful spending, the current utilization management tools have expanded beyond that purpose. They are now delaying or preventing appropriate care and treatments,” the organization wrote.

CMS proposed shortening the decision time for prior authorizations to seven days for non-urgent requests and 72 hours for urgent requests. ACR has asked the agency to align the timeline with policies in the Improving Seniors’ Timely Access to Care Act and further shorten the decision time for urgent requests to 24 hours.

“A 24-hour timeline is still too short in emergent cases but will allow providers to deliver urgent care needed to ensure the health and safety of their patients in most situations,” the letter stated.

The rule proposed adding an electronic prior authorization measure to the performance improvement (PI) category of the Merit-based Incentive Payment System (MIPS). ACR urged CMS to reconsider this addition, as rheumatologists struggle to report current PI measures without proper EHR capabilities. Providers cannot change EHRs to comply with the measure due to increasing practice costs.

ACR voiced opposition to including the electronic prior authorization measure until EHRs can report the measure without additional burden to providers.

Regarding gold cards, ACR supported the concept of a gold card program but encouraged CMS to ensure it is thought out and comprehensive. In addition, the gold card program should include treatments, including physician-administered drugs.

ACR also supported the requirement for payers to develop a provider application programming interface (API) but urged CMS to require payers to include information on drugs in addition to services to provide greater transparency.

“While we are encouraged to see the increase in transparency between payers and providers, the impacts of the API on everyday practices remain unknown and will not be understood until the APIs are rolled out to practices,” ACR wrote.

“We remain optimistic that these programs will increase transparency and alleviate administrative burden; however, the true impact of APIs on prior authorizations and care coordination will not be realized immediately and could bring unintended consequences.”

The letter supported the proposal to require payers to provide the reason behind prior authorization denials. ACR said this would allow a more straightforward path for resubmission or appeal when a request is denied.

Despite legislation and advocacy work from provider groups, provider burden stemming from prior authorization processes remains ongoing. Data from the American Medical Association (AMA) recently found that 88 percent of physicians described prior authorization burden as high or extremely high.

Practices complete an average of 45 prior authorizations per physician per week and dedicate almost two business days each week to prior authorizations. The majority of physicians (94 percent) said that the process delays access to necessary care at least sometimes, often, or always.