November 30, 2023
Healthcare and expertise teams help proposed interoperability and prior authorization rule
Healthcare and expertise teams help proposed interoperability and prior authorization rule

Photograph: Reza Estakhrian/Getty Photos

Healthcare and expertise teams need Medicare Benefit plans included within the Facilities for Medicare and Medicaid Companies’ proposed rule to increase entry to well being data and enhance the prior authorization course of.

MGMA, the Medical Group Administration Affiliation and WEDI, the Workgroup for Digital Knowledge Interchange, each mentioned they favor the inclusion of Medicare Benefit plans within the remaining rule. WEDI would additionally like CMS to establish alternatives to incentivize industrial payers to help rule necessities.

CMS proposes that plans be required to offer particular causes for prior authorization denials. Each MGMA and WEDI agree plans want a deadline to make prior authorization selections, however differ on that timeline.

WEDI agrees with the present CMS proposed timeframe of seven days for non-urgent requests and 72 hours for expedited requests, whereas MGMA needs to see that shortened to 48 hours for traditional prior authorizations and 24 hours for expedited prior authorizations. 

CMS mentioned its proposed normal is twice as quick as the present Medicare Benefit response time restrict.

The present time-frame will do little to mitigate the present challenges concerned with processing prior authorization requests in a well timed method in order to not delay care, MGMA mentioned. MGMA urges CMS to make clear within the remaining rule that these required time frames consult with remaining selections and to develop an enforcement plan that doesn’t totally depend on medical teams to make sure plan compliance, it mentioned.

MGMA and WEDI additionally need these provisions applied earlier than the present proposed date of January 1, 2026. CMS ought to make these necessities efficient instantly upon finalization of this rule, MGMA mentioned. WEDI recommends CMS give the business 36 months following the efficient date of the ultimate rule to adjust to the necessities.

CMS launched the proposed rule in December. One motive for implementing the adjustments is doctor and clinician burnout, mentioned Surgeon Normal Vice Admiral Vivek Murthy, throughout a press name in January.

Feedback have been due by Monday, March 13.


“Automating prior authorization is just one a part of attaining significant reform,” mentioned MGMA, in feedback to CMS on the interoperability and prior authorization proposed rule. “A lot work stays to be executed, together with efforts to offer higher transparency, cut back the general quantity of prior authorization requests and enhance peer-to-peer opinions.”

MGMA helps gold-carding initiatives, and whereas gold-carding applications have the potential to cut back burden and delays in care, solely 7% of practices report that MA plans have a gold-carding program obtainable.

In gold-carding, physicians who’ve a 90% prior authorization approval price over a six-month interval on sure providers can be exempt – or “gold carded” – from prior authorization necessities for these providers, in keeping with the American Medical Affiliation.

MGMA doesn’t wish to hyperlink digital prior authorization necessities to CMS’ High quality Fee Program. To hyperlink prior authorization to the Selling Interoperability element of Benefit-based Incentive Fee System would solely exacerbate pointless burden and work towards CMS’ purpose of decreasing doctor burden, medical workers time, and prior authorization-related prices, it mentioned.


The rule proposes to require sure payers to implement requirements that will allow knowledge change from one payer to a different when a affected person adjustments payers or has concurrent protection.
WEDI mentioned it strongly helps the suitable use of software program interface (API) expertise to advertise interoperability and enhance prior authorization processes. WEDI recommends a response time of two enterprise days for each the Payer-to-Payer and Affected person Entry APIs.

”We urge CMS to carefully monitor the business following the implementation date to find out if these response occasions must be modified,” WEDI mentioned. WEDI urges CMS to align the prior authorization proposals with the proposal to determine a nationwide normal for digital attachments and the anticipated enlargement of the Workplace of the Nationwide Coordinator for Well being Data Know-how certification program.


An AMA survey reveals that 94% of physicians report care delays because of prior authorization, 80% report it could possibly result in therapy abandonment and 33% report it could possibly result in severe adversarial occasions for sufferers.

Physicians spend nearly two enterprise days every week on prior authorization requests, and 35% have needed to rent further workers to deal with the executive burden, the AMA mentioned.

Twitter: @SusanJMorse
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Wendy Paul and Kyle Longhurst will provide extra element of their HIMSS23 session “Utilizing Machine Studying to Scale back Discharge Medicine Errors.” It’s scheduled for Thursday, April 20, at 2:30 p.m. – 3:30 p.m. CT on the South Constructing, Stage 4, in room S401.