CMS Health Tech Ecosystem adds electronic prior auth pledge

CMS is adding a new pledge to the Health Tech Ecosystem, one that aims to bring together healthcare payers, providers, EHR vendors and digital health developers to implement  electronic prior authorizations.

Stakeholders that sign on to the pledge voluntarily commit to moving electronic prior authorization "beyond minimum compliance requirements by implementing interoperable, end-to-end workflows across medical prior authorization processes." CMS said.

The pledge also includes a commitment to supporting seamless data exchange and improvements across prior authorization workflows consistent with the CMS Interoperability and Prior Authorization rule.

Prior authorization, a process in which providers obtain payer approval to ensure a service or medication is covered before providing it to patients, has long been a pain point in the healthcare delivery continuum. The process is often costly and delays care.

The government has taken several steps to ease the process, including implementing the CMS Interoperability and Prior Authorization rule. Also known as CMS-0057-F, the rule requires certain payers to meet specific prior authorization decision deadlines, provide denial reasons for all prior authorizations and collect data for reporting.

Per the Interoperability and Prior Authorization Final Rule, impacted payers -- including Medicare Advantage organizations and those offering Qualified Health Plans on the Federally-Facilitated Exchanges -- must implement various APIs to facilitate data sharing and create more efficient electronic prior authorization workflows by 2027.

Further, the government last year gained voluntary commitments from the nation's major health insurers to streamline prior authorizations. Participating insurers agreed to six actions to ease the process, including developing standardized data and submission requirements using FHIR APIs and showing proven reductions in medical prior authorization.

Adding an electronic prior authorization-focused pledge moves this work forward and brings it into the interoperability goals of the CMS Health Tech Ecosystem initiative.

The initiative, launched last year, has two broad directives: establish an interoperability framework and increase the availability of personalized digital health tools. Organizations from across the healthcare ecosystem have pledged to work towards these goals in numerous ways, from 'killing the clipboard' to advancing conversational AI capabilities.

Organizations that sign on to the new electronic prior authorization pledge will participate in working groups to align on CMS Interoperability and Prior Authorization Final Rule deadlines, as well as address workflow gaps and technical handoffs.

"When data flows seamlessly -- between a provider's EHR, the payer's electronic prior authorization interfaces, and a patient's health record -- the entire system becomes more responsive, more accountable, and more focused on what matters most: getting patients the care they need without unnecessary delays or burdens," CMS Administrator Mehmet Oz, M.D., wrote in the online blog.  

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.