Electronic Prior Authorization Processes Must Be Expedited and Include Cancer Drug Treatments

March 14, 2023

The Association for Clinical Oncology (ASCO) submitted comments in response to the Centers for Medicare & Medicaid Services (CMS) “Interoperability and Prior Authorization for MA organizations, Medicaid and CHIP Managed Care and State Agencies, FFE QHP Issuers, MIPS Eligible Clinicians, Eligible Hospitals and CAHs” proposed rule. The intent of the proposal is to streamline prior authorization by requiring Medicare Advantage plans, Medicaid plans, and Qualified Health Plans (QHP) on Federally Facilitated Exchanges (FFEs) to establish an electronic prior authorization process that would be integrated into a provider’s workflow.

ASCO commends CMS for taking steps to improve the prior authorization process and believes that, when combined with the recommendations in ASCO’s comments, the proposed reforms will improve beneficiary access to necessary and life-saving services and help ease the administrative burden on physicians.

While ASCO supports the proposed provisions that streamline prior authorization, the Association strongly urges CMS to address two overarching concerns with the proposed rule.

  1. ASCO strongly urges CMS to expedite the implementation timeline for provisions finalized in this rule for all plans and require compliance with finalized proposals in contract year 2024. Allowing current prior authorization practices to continue for several additional years (until 2026 as proposed in this rule), would limit progress, and continue to put patients in harm’s way. 
  2. We strongly urge CMS to include drugs—which are currently excluded--in the electronic prior authorization program and application programming interface (API) requirements. A significant portion of cancer care requires patient access to life-saving drugs and the prior authorization requirements associated with these drugs are extremely burdensome for patients and their oncologists. The omission of drugs from this rule is deeply concerning and provides no relief for the patients and providers who will continue to experience delays in obtaining necessary care.

Other comments to CMS include the support for the agency’s proposal to require impacted payers to build and maintain a Prior Authorization Requirements, Documentation and Decision (PARDD) API that would automate the process for providers to determine whether prior authorization is required, identify prior authorization information and documentation requirements, as well as facilitate the exchange of prior authorization requests and decisions from their electronic health records (EHRs) or practice management system. ASCO strongly supported CMS’ proposal to require impacted payers to provide a clear, concise, and specific reason for denied prior authorization decisions regardless of the method used to send the prior authorization request.

ASCO comments express serious concerns over the lack of oversight and enforcement for plans that do not comply with the timelines to return a prior authorization decision back to the provider. CMS states in the rule “if a payer fails to meet the timeline for approval or other decision, providers should contact the payer to obtain the status of the request and determine if supporting documentation is needed…” Putting the onus back on a provider when the payer fails to comply with timelines established in this rule would only exacerbate the current administrative burdens associated with prior authorization and provide little incentive for plans to improve.

ASCO asserts that if a physician does not receive a prior authorization decision within the set timeframe, the default response should be an approval of the prior authorization request. The Association strongly urges CMS and other regulatory agencies to hold payers accountable for the timeliness of prior authorization determinations.

To encourage providers to adopt electronic prior authorization processes, CMS proposed a new measure for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program and for eligible clinicians under the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS). Providers would report on the number of prior authorizations (excluding drugs) that are requested electronically from a PARDD API using certified EHR technology under the proposed measure. ASCO strongly opposes this measure and disagrees with CMS that this is an appropriate way to encourage provider adoption of electronic prior authorization.

Time-consuming, labor-intensive prior authorization processes adds a significant burden on patients and providers. While many prior authorization requests may be initiated electronically via individual payer portals, subsequent interactions and requests for additional information are frequently conducted via fax or phone, leading to delayed communication, slower response times, and delays in patient care. We commend CMS for taking initial steps to require electronic prior authorization among several payers, and we urge them to incorporate our comments and recommendations to continue improvements to the prior authorization process.

Read the full comments.

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