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Navigating the new prior auth: What CMS-0057 means for providers and their practices

09/04/2024

by Chris Scoggins

Prior authorization. For many patients and providers, those words leave a bitter taste in the mouth. But why?

Originally created to protect patients from costly medical expenses, prior authorizations have become something of a pain for practitioners and consumers alike. If you’re a patient who’s been told you need an important procedure only to experience the anxiety of insurance denying it with little to no explanation, you know what I’m talking about. Conversely, if you’re a provider, you know how frustrating it is when you must delay patient treatment for lengthy and often unclear appeals processes.

Enter CMS 0057-F, the CMS Interoperability and Prior Authorization Final Rule active as of April 2024. This rule improves the prior authorization process by emphasizing improved health information exchange, more data-centric practices, and reductions in administrative burden for payers. Those are some welcome improvements for most providers, who are required to implement changes for the ruling by January 2026 or 2027 in some cases.

Sounds great, right? Before you start celebrating, there are challenges ahead, many of which some clinics and healthcare systems are not equipped to handle. Are you one of them?

What Does CMS 0057-F Mean For Your Healthcare Practice?

Let’s take a surface-level look at a few high-level impacts this rule will make on the interoperability and prior authorization processes. First, the good news:

• Standardization & Transparency: Requirements and transparency around the prior authorization will now be clearer and the process and speed by which supporting documentation can be retrieved means likely fewer appeals and faster approvals. If an authorization is rejected, health plans are now required to explain the reasons for the denial.
• Clearer Appeals Process: Gone are the days of a vague appeals process. With clearer guidelines and requirements for reviewers to be qualified professionals with relevant expertise, the burden of the appeals processes should be smaller, which means faster care for patients.
• Reductions in Administrative Burdens: The time, resources, and money placed into this process is staggering. According to a 2022 survey from the American Medical Association, physicians and staff spend nearly 14 hours a week on prior authorizations alone. This new ruling is estimated to save the industry $15 billion over the next decade by centralizing the prior authorization process within electronic health records (EHR) systems.

However, with every change, there are challenges too:

• Effectiveness Will Vary By State and Insurance Plans: The speed at which healthcare systems embrace the integration of these digital technologies will determine how effective this system can be. Despite some initial resistance, roughly 80% of providers now use an EHR system. However, many systems have limitations on their data interchange across networks. If some systems can’t talk to one another, delays and frustration will occur. Additionally, partial coverage means this ruling primarily impacts Medicare Advantage and Part D plans but has a lessened impact on Medicaid and CHIP patients.
• Change Creates Disruption, and Disruption Hurts Your Care: This is universal for any significant change, but for many clinics and healthcare systems, setting up the technological infrastructure, job training, and change management is a massive undertaking. Training in new processes to share information across member plans will complicate or cause delays in the prior authorization process.
• Differentiations in Tech Means Delays in Your Process: An API platform, or application programming interface, is what allows health plans and systems to talk to one another via EHR systems to create a successful data exchange of patient information. As of now, there’s no universal network or interchange used by all health plans for all providers across all systems, which means vital information can’t always be shared timely or efficiently.

The Bottom Line: Create An Interoperability Solution Based Mindset

Every change comes with good and bad. There is great potential in this new ruling to improve your practice by reducing your administrative burdens and promoting faster, more transparent care. However, as a provider, you’ll need the tools and infrastructure in place to make it a success, or risk lagging.

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Whether you are a small provider office or a member of a significant healthcare system, you’ll need the right API platforms, EHR systems, and personnel training to navigate this change. If you’d like to learn more about how Sendero can help you navigate all aspects of this change before the deadline, reach out to us to learn about our history of success in helping healthcare professionals navigate technology and process changes for the better.

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