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FOUR THINGS YOU NEED TO KNOW ABOUT THE FINAL CMS PRIOR AUTHORIZATION RULE

How health plans can prepare

--------------------------------------------------------------------------------

On January 17, 2024, The Centers for Medicare & Medicaid Services (CMS)
finalized a rule to advance interoperability and improve prior authorization for
Medicare and Medicaid patients. At Cohere Health, we are especially encouraged
by the stipulations for improving prior authorization included in the rule and
see it as a step in the right direction. This initiative will improve
transparency, reduce physician burden, and lead to faster patient access to
care. Cohere sees the CMS final rule as an opportunity for plans to evolve from
transaction-focused prior authorization to transformational utilization
management—an approach that improves the whole patient journey and enables more
successful value-based care arrangements. The implementation of intelligent
prior authorization is the first step in this evolution.

The final rule is based on the Advancing Interoperability and Improving Prior
Authorization Proposed Rule, published in December 2022. Cohere provided
feedback to CMS during the rule’s comment period last spring. The final rule
remains largely similar to its proposal. However, some key differences include:

 * The implementation deadline for FHIR-based APIs was pushed back to January 1,
   2027. However, payers must publish metrics on Provider API usage by January
   1, 2026
 * CMS announced an enforcement discretion of HIPAA X12 278 standard for
   interoperability APIs
 * Health plans are required to publish their first metrics around authorization
   rates by March 1, 2026.
 * Authorization status was added to patient access, provider, and
   payer-to-payer APIs
 * Qualifying health plans on federally facilitated exchanges are excluded from
   the turnaround time requirements of 72 hours for expedited requests and seven
   days for standard requests

Health plans serving Medicare and Medicaid patients that implement the
infrastructure and technology to support this transition proactively will find
themselves well-situated to navigate compliance with the rule and future
regulatory changes to the prior authorization landscape.

HERE ARE FOUR CHANGES TO PRIOR AUTHORIZATION IN THE NEW CMS FINAL RULE


 * Health plans will be required to build and maintain a Fast Healthcare
   Interoperability Resources (FHIR) Application Programming Interface (API)
   that has a list of covered items and services, can identify documentation
   requirements for prior authorization approval, and supports a prior
   authorization request and response by January 1, 2027. 

These prior authorization APIs must also communicate whether the payer approves
the prior authorization request (and the date or circumstance under which the
authorization ends), denies the prior authorization request (and a specific
reason for the denial), or requests more information.

This requirement would ease the provider burden by establishing clear,
instantaneous communication on whether a prior authorization is required, which
patient information and documentation is needed to evaluate appropriateness, and
accelerating and automating additional information requests and final prior
authorization decisions, for a selected service.

Cohere’s intelligent prior authorization solution, Cohere Unify™, helps
providers determine if a prior authorization is required and digitizes prior
authorization intake across all channels, including fax, portals, and EMRs. The
solution includes in-platform nudges that automatically prompt for missing
information before the request is submitted, and uses artificial intelligence to
incorporate relevant patient information from the EMR. The solution also
provides intelligent decisioning, based on clinical evidence, NCD/LCD, and
plan-specific policy guidelines.

Cohere already has FHIR-based APIs in production today (PAS, CRD, DTR). 

 * Health plans will be required to communicate the reason for denial with the
   physician, regardless of the channel used to submit the request by January 1,
   2026.

By requiring plans to communicate with physicians and their staff after issuing
a denial, health plans will provide context for their evaluation process and
increase transparency between themselves and providers. This additional insight
into the decisioning guidelines will help providers who repeatedly submit
requests for the same procedures and may result in the submission of corrected
requests in cases rejected due to missing or incomplete information.

Cohere’s intelligent prior authorization solutions were developed around the
fundamental principle of increasing transparency between providers and health
plans to deliver faster approval of quality care for patients. By improving
interoperability, and the secure exchange and utilization of health data, payers
and providers can work together to deliver better outcomes for patients.
Cohere’s platform provides reasoning for denials, and the care path guidelines
used to intelligently decision authorization requests are publicly available.

 * CMS will now require a shorter turnaround time for urgent and nonurgent
   requests, with a timeframe of 72 hours for urgent and seven days for
   non-urgent requests. This provision goes into effect January 1, 2026.

The rule will require impacted payers (excluding qualifying health plans on the
federally-facilitated exchanges) to send prior authorization decisions within 72
hours for urgent requests and seven days for standard requests. Currently, the
long wait times between request submission and authorization decisions delay
patients’ access to care. These delays present additional problems for patient
populations affected by social determinants of health, where service delays can
affect the continuity of and access to care.

With the digitization of prior authorization offered by Cohere’s intelligent
prior authorization solutions, 83% of requests are immediately approved. This
leads to faster access to care and ultimately delivers better outcomes. In the
small number of cases where clinician review is required, Cohere averages a
4.5-day turnaround time and only nine hours for expedited cases. 

 * Health plans will be required to publicly publish certain prior authorization
   metrics annually, with the first set of metrics to be published by March 1,
   2026.

CMS will require impacted payers to publish the following metrics: a list of all
items and services that require prior authorization; the percentage of prior
authorization requests that were approved, denied, approved after appeal, and
approved after an extension was granted, for each standard and expedited
requests; and median turnaround times, for each standard and expedited requests.

To increase transparency around authorization decisions, health plans would be
required to publish prior authorization metrics on their website. Cohere
supports this proposed requirement and the usage of prior authorization metrics
to improve the overall quality of care for patients. When all of the
stakeholders in the utilization management process have transparency around
metrics, it is possible to move toward value-based care. At Cohere, we have our
own policy of sharing metrics quarterly with health plans.

Cohere is encouraged by the progress made with the finalization of the CMS final
rule and its focus on improving the cumbersome prior authorization process.

You can read the full requirements of the Interoperability and Prior
Authorization Final Rule, here.

If you would like to speak with us further about how the CMS ruling will impact
your health plan, connect with us.

Published On: January 19th, 2024Categories: Blog, Compliance 101

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ABOUT THE AUTHOR: ALINA CZEKAI

Alina M. Czekai, M.P.H., is Vice President of Value-Based Care Strategy at
Cohere Health. Previously, Alina served as a Senior Advisor to CMS Administrator
Seema Verma, leading the agency’s relationships with the healthcare industry and
maximizing public support for CMS’s priorities and overarching mission. In her
current role, she is responsible for devising and executing the company’s
strategy for value-based care, including new product development and
partnerships.
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