CMS proposes rule to set Part D electronic prior authorization standards

By | June 18, 2019

Dive Brief:

  • CMS on Monday released a proposed rule updating the electronic prior authorization requirements for Medicare Part D plans.
  • The proposal would require plan sponsors to support a certain version of the National Council for Prescription Drug Program SCRIPT standard for such transactions.
  • Under the standard, providers can use an electronic prescribing system or EHR with electronic prescribing capabilities to determine whether a plan requires prior authorization for the medication being prescribed. If it does, that information could be submitted in real time.

Dive Insight:

Streamlining the prior authorization process through electronic means has been a goal for HHS, and the head of the Office of the National Coordinator for Health IT, Don Rucker, spoke earlier this month about encouraging more providers to adopt the process.

Rucker told the audience at Academy Health’s annual research conference current prior authorizations practices are a “non-computerized kabuki of payment” and should be overhauled. He said it “may be the battlefield” for better integrating financial, clinical and quality data.

Improved integration also requires interoperability, an even greater focus for ONC. The department, along with HHS, proposed rules earlier this year, aiming to stem information blocking and improve electronic sharing of information between payers, providers and patients.

Providers have generally cheered the spirit of those efforts, but have also spoken out strongly against prior authorization requirements. A recent American Medical Association survey found 85% of physicians say PA interferes with continuity of care.

That survey showed part of the problem was lack of EHR integration, with only a little more than 20% of doctors saying their systems allowed for electronic approvals. The HHS proposal would also help the more than 75% who said they have difficulty determining when a prescription or service requires PA.

CMS Administrator Seema Verma argued the Part D proposal would be an improvement for providers. “This proposed rule would reduce the time it takes for a patient to receive needed medications and ease the prescriber burden by giving clinicians the flexibility and choice to complete prior authorization transactions electronically,” she said in a statement

Electronic prior authorization has been shown to improve turnaround times and dispense rates as well as medication adherence. CAQH, a nonprofit focused on healthcare businesses processes, estimates the medical industry could save $ 4 billion a year with greater adoption of ePA.

Comments on the proposed rule are due Aug. 16.

Healthcare Dive – Latest News