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  • Washington Highlights

    AAMC Comments on CMS Proposals to Reduce Prior Authorization Burden


    Phoebe Ramsey, Director, Physician Payment & Quality

    The AAMC submitted comments to the Centers for Medicare & Medicaid Services (CMS) on Jan. 4 in response to a notice of proposed rule-making, “Reducing Provider and Patient Burden by Improving Prior Authorization Processes, etc.”

    Under the proposal, the CMS would require certain payers — including Medicaid, the Children’s Health Insurance Program, and plans under the federal exchange — to build and support a variety of application programming interfaces (APIs) to facilitate data exchange and information about prior authorization requirements. The notice builds off of interoperability policies finalized earlier this year and is intended to leverage health information technology (IT) tools to streamline prior authorization and reduce burden on patients and providers.

    Due to the condensed comment period, the AAMC limited the scope of its comments, which included general support for improvements to prior authorization processes to reduce burden. The comments emphasized continued broader opposition to prior authorization and that medically necessary care should not be denied because a physician or patient cannot jump through often complicated and opaque requirements that differ across health care payers. The comments also stressed that adopting a standardized, straightforward form of requirements and process for prior authorization for all payers would reduce burden and that the CMS should at a minimum also include Medicare Advantage (MA) organizations as payers subject to the proposals.

    Additionally, the CMS included a request for information (RFI) on how to accelerate standards related to social risk data, from data collection to promoting exchange of data. The AAMC urged the CMS to take the lead in building from prior consensus efforts to ensure future standards for data collection and exchange are both translatable from the patient screening tool to coding risk data for claims and flexible to ensure they are appropriate for each community’s particular needs. The comments also emphasized the potential of Z-codes in the ICD-10-CM code set to improve utilization of data collected to inform specific interventions and coding on claims for reimbursement.

    The AAMC noted that health care payers could promote the collection and exchange of social risk and social needs data by working to improve risk adjustment models and appropriately pay providers for care that addresses the social needs of their patients.