The CAP asked the CMS to streamline prior authorization processes, reduce physician practice burdens, and prevent patient care delays in Medicare Advantage (MA) and other public health plans. The CAP believes prior authorization often interferes with a patient’s ability to receive timely and appropriate services/care and has worked to reduce administrative and reporting burdens for pathologists and their laboratories.

The CAP responded to a proposed regulation to improve the electronic exchange of health care data and streamline processes related to prior authorization on March 13. The CAP emphasized how streamlining or automating prior authorization and other utilization management processes is critically important, and that it is imperative that any cost-control measures balance other considerations and continue to ensure access to timely and appropriate care.

In the letter the CAP cited how “recent American Medical Association (AMA) survey data show that 93% of physicians report care delays or disruptions associated with prior authorization, and as was explained in the HHS Office of Inspector General report that highlighted concerns about prior authorization within MA, inappropriate denials may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.” Therefore, the CAP asked the CMS to finalize, with some strengthening adjustments, the changes proposed for:

• electronic options for prior authorization
• requirements for payers to provide status of prior authorization requests and reason for denial of authorization
• requirements for prior authorization decision timeframes and communications
• public reporting of prior authorization metrics
• “gold carding” programs for prior authorization

The CAP said it wants the CMS to finalize these changes with some strengthening adjustments – especially in protecting patient data, shortening the timeframes, accountability/transparency, and adding protections against retrospective denials.