New Federal Rule Aims to Expedite Authorization Process, Enhancing Patient Care

By Annie Stephan Jan 17, 2024 11:08 PM EST

Highlights of the New Federal Rule

A federal initiative grips headlines as the Biden administration unveils its commitment to expediting healthcare processes. At the center of this transformative move is the contentious prior authorization routine. Known for its prevalent use by insurers, the administration seeks a thorough overhaul of this process that many argue impairs patient care.

New Federal Rule Aims to Expedite Authorization Process, Enhancing Patient Care — (Photo : Pexels/Total Shape)

Unraveling the Prior Authorization Knot

Prior authorization, a mechanism widely deployed by insurance providers, has invited sharp criticism from doctors and patients alike. Frequently, this tool translates into denials of medical care that many health professionals deem critical for their patients.

The Core Components of the Biden Rule

The directive in question, an output of the Centers for Medicare and Medicaid Services (CMMS), mandates health insurers in Medicare Advantage, Medicaid, or participating in the ObamaCare exchanges to adhere to new response deadlines. Insurers must step up for requests categorized as expedited, bringing down their response time to 72 hours. Meanwhile, standard requests will have a slightly longer, yet considerably reduced, allowance of seven calendar days.

What Does Transparency Under the New Rule Entail?

A potent requirement brands this rule. Insurers must state explicit reasons when they turn down a prior authorization request and maintain transparency in their prior authorization metrics, disclosing these figures publicly.

The Role of Digitization in Streamlining Patient Care

Through the voice of Health and Human Services Secretary Xavier Becerra, the Biden-Harris Administration underscores the urgency of shortening patient wait times. Echoing the sentiments of countless American citizens in the waiting limbo for insurer approvals, the administration reveals plans for a drastic shift. It proposes leveraging digitization to make the approval process faster and more efficient, setting the stage for enhanced patient care.

How Does the Rule Influence Health Care Providers and Insurers?

Released after a year of anticipation, this rule could redefine healthcare for millions of Americans. It is a testament to the administration's staunch efforts towards challenging insurers to modify one of healthcare's most hotly debated practices.

Emerging Consensus on Overhauling Prior Authorization

Interestingly, the voices calling for an overhaul of prior authorization within Medicare Advantage resonate across party lines. Members from both legislative chambers have expressed a desire for the White House to cement regulations addressing this matter.

The Ongoing Debate

Positioned in the firing line, insurers have defended the necessity of prior authorization. They argue its role in reducing costs and preventing unnecessary and extravagant treatments. Doctors and patients, on the other hand, see this protocol often posing an obstacle to needed patient care, burdening care providers with extensive paperwork or prolonging waiting periods for decisions.

Insights from KFF Study

A revealing study conducted by KFF shed grim light on the prevalence of prior authorization requests in the preceding year. Out of over 35 million requests from Medicare Advantage plans, over 2 million came back either fully or partially rejected. The study also highlighted that in 2022, virtually all Medicare Advantage enrollees took part in a plan demanding prior authorization for some services, unlike traditional Medicare patients.

The Gaps in the New Rule?

While the rule brings about notable changes, it does not cater to Veterans availing care through the Department of Veterans Affairs, nor does it cover the staggering 153 million Americans under private, employer-supported plans.

The Promise of Improved Efficiency

For some, the standardized request time frame in the new rule slices the existing decision period in half. The Health and Human Services department also projects these changes to increase efficiencies, potentially saving clinics and hospitals $15 billion within a decade.

Are Legal Services a Necessity in Navigating the Changes?

Given the far-reaching legal implications of such a policy shift, the need for professional legal help stands highlighted. Consulting with legal experts with experience in healthcare regulation changes can serve as a pillar of support in adapting to the new rule.

Embracing this change begins with knowledge. Start now. Equip yourself with the necessary information and take the first step towards leveraging these timely changes. Seize the opportunity to enhance patient care with timely authorizations.