The impact of the CMS proposed rule on the authorization process

Prior authorization (PA) is a process where healthcare providers must obtain approval from insurers before delivering specific treatments or services. A PA can introduce challenges affecting patient care, including delaying treatment initiation. 

The American Medical Association (AMA) reports that 94% of physicians have experienced delays in necessary care due to PA requirements. The delays can lead to adverse events, nearly four physicians noted that PA has resulted in hospitalization, permanent impairment, or even death for patients. The CMS proposed Rule is intended to improve this process to create a more patient-centered approach to care. 

The CMS proposed a rule. 

The CMS proposed rule centers around reforming practices within Medicare Advantage (MA) plans to address issues related to prior authorization. By limiting insurers' reliance on overly restrictive internal or proprietary courage criteria that deviate from Traditional Medicare, the proposed rule looks to prevent unnecessary delays or outright denials of medically necessary services.  

The main difference introduced. 

Medicare advantage (Part C)

• There is strengthened accountability amongst insurers and healthcare organizations to ensure appropriate care. 
• It limits the reliance on restrictive internal criteria that deviate from Traditional Medicare. 
• The prior authorization process is more transparent. 
• There are guardrails on the use of AI to prevent inappropriate denials of care. 

Transparency and consumer tools 

• Requires MA plans to share complete provider directory information with CMA. 
• It improves the Medicare Plan Finder to provide a personalized, user-friendly experience. 
• There is an improvement in the ability of enrollees to compare MA plans and provider availability. 

The impact on prior authorization processes

PA is often seen as a practice that poses challenges to the healthcare system, something noted by the CMS and the American Hospital Association. The proposed rule stems from the need to address these challenges by recommending practices to reduce the inappropriate use of prior authorization in MA plans. The rule aligns decisions more closely with traditional standards. 

As the excessive burden placed upon healthcare organizations is relieved by a streamlined process, patients are less likely to experience delays in accessing treatments or medications. It allows organizations to take a more patient-centered approach to healthcare systems without third-party obstructions. 

The role of HIPAA compliant email in the improvement of prior authorizations 

HIPAA compliant email allows for real-time distribution of submissions, and responses to payer inquiries, and helps patients receive authorization decisions without prolonged waiting periods. Throughout the process, documentation created through centralized email interactions creates searchable records accessible during audits. One of the central features of HIPAA compliant email, encryption also ensures that the protected health information (PHI) shared during the authorization process remains secure. 

FAQs

What is provider directory information?

Provider directory information includes details about healthcare providers like their names, specialties, office locations, and whether they accept new patients. 

What is the standard of encryption for HIPAA compliant email?

Transport layer security (TLS) 2 or above.

What is an authorization list?

A document or system that outlines specific procedures, treatments, or medications.