Doctor groups ask CMS to rethink prior authorization reforms

More than 100 physician organizations sent a letter to the Centers for Medicare and Medicaid Services expressing “strong concerns” that the agency may be too focused on automation as the only way to implement prior authorization reforms.

The letter, led by the American Medical Association, applauds the agency for tackling the challenging issue of prior authorization (PA) as part of its Patients Over Paperwork initiative to reduce administrative burdens in healthcare.

However, the doctor groups take aim at the Da Vinci Project, a payer-provider led effort to leverage HL7’s Fast Healthcare Interoperability Resources (FHIR) to exchange critical data required for value-based care delivery.

“We are aware that CMS has invested heavily in the Da Vinci Project, which leverages technology to facilitate electronic exchange of clinical data by extracting information from physicians’ electronic health records,” states the letter to CMS Administrator Seema Verma. “While Da Vinci holds promise, there are a series of issues with exclusively relying on technology to address the burdens of PA.”

The medical societies contend that focusing on just the technological aspects of prior authorization will not solve the problem but could set the stage for increased use of PA.

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“Solely concentrating on process automation may set the stage for increased PA volume because document exchange will be easier and faster,” the groups told Verma in their letter. “Patient care delays will continue, as manual review of medical documentation is often required following the instantaneous electronic exchange of data.”

In addition, they charge that the Da Vinci Project “will allow payers unprecedented access to EHRs” and that “protections are needed to prevent plans from inappropriately accessing patient information, coercing physicians into using technology (e.g., through contracts), or interfering with medical decision making.”

Further, the organizations contend that the Da Vinci Project “represents nascent technologies that have yet to be widely implemented,” and as a result, “the costs and the timeframe availability across EHR vendors remain unclear.” They also make the case that “Da Vinci likely will not offer relief from PA for small practices in the near future.”

While automation is important, the medical societies told Verma that it is only one of five major reforms they believe are needed to address the problem of prior authorization, which is negatively impacting patient care and has led to serious adverse events.

“We strongly urge CMS to implement a comprehensive strategy to reduce the harms and burdens of PA by facilitating payer adoption of the following principles: selective application of PA to only ‘outliers;’ review/adjustment of PA lists to remove services/drugs that represent low-value PA; transparency of PA requirements and their clinical basis to patients and physicians; protections of patient continuity of care; and automation to improve PA and process efficiency,” the groups advised.

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