The Centers for Medicare & Medicaid Services (CMS) recently revealed that they have finalized a transformative rule, ushering in a new era for increased access to health information and a refined prior authorization process. Here are the top five takeaways from this game-changing announcement
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1. Expedited Prior Authorization
One of the most substantial aspects of this rule is the streamlined prior authorization process for impacted payers. By 2026, they will need to deliver prior authorization decisions within 72 hours for urgent requests and within seven calendar days for standard requests. For some payers, this means halving their current decision-making time, mitigating uncertainty, and potentially quickening the delivery of essential healthcare services.
2. Increased Transparency
In an effort to provide clarity for healthcare providers, the rule requires that impacted payers explicitly state a reason for denying a prior authorization request. This will facilitate a more streamlined resubmission or appeals process. This level of transparency is a considerable move towards effective communication and fairness within the healthcare system.
3. Public Reporting
The rule obligates impacted payers to openly report prior authorization metrics, fostering accountability and transparency. This public reporting echoes the metrics that Medicare Fee-For-Service (FFS) currently makes publicly available, illustrating a commitment to maintaining a fair and open healthcare system.
4. Leveraging of Digital Technology
Falling in line with the digital era, the rule mandates certain impacted payers to implement a Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Prior Authorization application programming interface (API). By automating the end-to-end prior authorization process, this innovative utilization of technology will undoubtedly create a more efficient electronic prior authorization process between providers and payers.
5. Movement Towards Efficient Healthcare System
Finally, the changes introduced by the rule aim to alleviate the administrative burden on the healthcare workforce. By creating an efficient channel for data flow and streamlining intricate processes, it will allow healthcare workers to dedicate more time to direct patient care, thus mitigating unavoidable delays in treatment.
All in all, the final rule by CMS represents an important milestone in the disruption and digital transformation of the healthcare landscape. By championing more streamlined processes and advocating for transparency, the CMS has not only made substantial strides towards better health outcomes but has also begun to reshape the patient experience in a digitally driven world.
Mystaffolgy has written in greater detail on the topic of Healthcare and Prior Authorization. This article has been edited by Michael Brethorst and written with the aid of Artificial Intelligence.
