The Impact of the New Prior Authorization Rule

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Tom Haederle

Prior authorization means getting approval from your health plan before scheduling a medical service. Insurers called it a plus, a way to protect patient health by making sure a procedure is the necessary and correct one. Many patients and clinicians, however, say prior authorization has become an administrative nightmare, creating miles of red tape that can delay or even deny needed medical care for patients.

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Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In mid-January and with strong support from the AHA, the Centers for Medicaid and Medicare Services issued a final rule designed to address some of the widespread complaints about prior authorization and the difficulties it can cause. CMS says the new rule will "help ensure that patients remain at the center of their own care."

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Tom Haederle

If so, how that will help is the subject of today's podcast. Joining me today to talk through this are Andrea Preisler, senior associate director of Administrative Simplification Policy with the AHA; Jennifer Cameron, executive director of Patient Access, Children's National Health System; and Dr. David Jacobson, division chief of blood and marrow transplantation with Children's National Hospital. Thanks, everybody again for joining me today.

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Tom Haederle

I really do appreciate it. Jennifer, I'd like to start with you, if we could. Given your access role at Children's. What have you seen firsthand? What's the impact been that you've seen on your patient population, children and families from how prior authorization is used or misused today?

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Jennifer Cameron

Yeah, I think currently it creates some challenges and some barriers. When I say that, I think about the time it takes sometimes to move patients through the approval process. The things that the payers are looking for is really making sure the patients need. Sometimes it's FDA guidelines or even their own clinical criteria. And then we Children's National on the other side, taking it from the provider perspective, trying to marry those two together.

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Jennifer Cameron

And sometimes you end up with denials, and we have to appeal and loop that provider in to help support that appeal conversation or it appears to move patients through. Many times it's a lot of back and forth with faxing or online portals and all of the different methods that we have to go about to get these patients approved.

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Jennifer Cameron

Ultimately, we continue to push through so we can get the outcome that's best for the patients and families. So that's the kind of world that is now. Do we always agree with the criteria? Not necessarily. But we understand it. And then, you know, our provider group, we'll have a conversation with the health plan to help kind of move those patients through. Most services than before require authorization

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Jennifer Cameron

than they've done in the past. So we've seen a shift in the industry that way that more services require authorization.

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Tom Haederle

Well, I'm sure that's made the whole process much more time consuming. But I would think in some instances it probably results in a delay of care or even denial of care that really is necessary. So how do you reconcile, you know, possibly putting a patient's own health at risk because the payor wants some information that may not really be necessary from your point of view?

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Jennifer Cameron

Well, I would say we always lean towards best for the patient. And we will consult with our providers, and if it's that it must be done then we have to go about doing it. And then we continue to negotiate and talk with the payer on the back end to move it through. But the key is what's going to be best for the patient.

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Jennifer Cameron

And we really lean to our providers. If our providers feel that is something that has to happen, then we have to do what's best for the patient. So that's the approach we take. Ultimately, we want to get it approved and many times it may be another test or additional bloodwork or something along that line. And we'll go ahead and get that done and resubmit.

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Tom Haederle

to David here. According to a: 2022

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David Jacobson, M.D.

Sure. We do see that sometimes. I deal with the blood and marrow transplantation, which is a very expensive therapy. So there's certainly prior authorization. And we need to make sure that the insurance is on board before proceeding with any case. But I would echo what Jennifer said earlier, but sometimes it seems it takes unnecessarily long and requires a lot of back and forth. Patients that absolutely need the therapy and have a very life threatening disease,

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David Jacobson, M.D.

a patient with leukemia, for example, they will definitely get the therapy. There are some patients, though, that are sent to us with more elective type of indications, such as sickle cell disease or Beta thalassemia where the treatment doesn't need to be done immediately. But in those patients, once the hassles start building up, we have occasionally seen that people just get tired of the wait, and give up or go somewhere else.

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David Jacobson, M.D.

So it can be problematic.

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Tom Haederle

I imagine it must be frustrating at times to feel like you're being second guessed as a care provider, or a direct care provider, or a clinician on scene dealing with the patient, and have somebody sort of asking questions who may not be that familiar with the patient's history and, and sort of second guessing your decisions. How does that impact your day to day work?

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David Jacobson, M.D.

It's hard. I mean, I think that, I think that checks and balances are super important. Don't get me wrong, but we have a very experienced team of transplant physicians, for example. And, sometimes it does seem like we have to go on the phone with a physician that's much more, much more general and dealing with a lot of different specialties

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David Jacobson, M.D.

and they're definitely not necessarily the most up to date in our field. So I wish there were ways to improve the process.

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Tom Haederle

Right, I hear you, it sounds like there certainly is room for improvement. And hopefully that's what this CMS final rule, at least has been designed to do that. We're hoping that it does. Andrea, I was thinking your very job title, administrative simplification has got to be music to many people's ears because health care system can be so complex in the first place.

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Tom Haederle

How has the widespread practice of prior authorization strayed from its original purpose, if it has, in your opinion? And a second part to that question, if a patient, it's a little bit different. But if a patient's request is denied by their insurer, what are their options?

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Andrea Preisler

I absolutely think that prior authorization as it was initially designed has strayed from its initial intent. Its intent was to make sure that patients receive the appropriate care at the appropriate time. It's now morphed into, as Jennifer alluded to, there are just voluminous prior authorization requests. And in my opinion, and I think the data supports this - prior authorization really gets in the way of that patient, physician or patient-provider relationship and can really interfere with ensuring that the patient receives the care in a timely manner that their provider, you know, in their medical judgment, thinks is the best treatment.

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Andrea Preisler

So I really think it has strayed from its initial intent and is being abused at this point.

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Tom Haederle

As to options that people can pursue if they're denied a claim or a procedure, what can they do? Can it be fought? Can it be appealed? Can it be successfully overcome?

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Andrea Preisler

Patients and providers do have options when it comes to initial prior authorization denials. That being said, those options are incredibly cumbersome. They often involve, as both Jennifer and Doctor Jacobson alluded to, those peer to peer conversations which can take often a long time to schedule. Often, you know, Doctor Jacobson, as a transplant surgeon, may be talking to, say, a gynecologist to try to get a treatment approved.

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Andrea Preisler

So you're often not really talking to a peer. Right? So that's part of the problem is while these appeal processes take a long time, they're very arduous. Meanwhile, the patient is waiting for this very needed treatment, right? Those people that appeal often have a very hard time reaching an approval. And oftentimes that initial denial will just result in complete abandonment of care altogether.

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Andrea Preisler

And that's also highly problematic.

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Tom Haederle

As you and I know, Andrea, being, employees of the American Hospital Association, we've watched this process very carefully and made some recommendations that CMS seems to have heeded - some of them - in its final rule that was released in January. Can you explain some of the major changes give a broad overview of what might be done differently in the future as a result of CMS action?

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Andrea Preisler

We at the AHA are thrilled with this new, CMS interoperability and prior authorization final rule, as you mentioned, released in January. And what this rule is attempting to do is taking that incredibly manual process of prior authorization with all of the documentation requests, faxing the proprietary portals, etc., etc.. Trying to take that and make it into a fully electronic process, end-to-end that all takes place within the provider's actual EHR or practice management system.

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Andrea Preisler

So the idea here is to get rid of all those phone calls, all those faxes, snail mail, portal documentation requests and take that and really make it so that a provider, when they're sitting with a patient, determining that a particular treatment is the most appropriate...presses a button and is able to get an immediate prior authorization approval back.

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Tom Haederle

That sounds like an enormous step forward if this plays out the way the rule is intended to. Jennifer, from your point of view, and following up on that, if the rule is implemented and achieves what it's designed to do - from the point of view of a family coming into Children's National for care, let's say, what would be different about the experience going forward

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Tom Haederle

in a positive way? How might they see improvement?

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Jennifer Cameron

Yeah, I think if it works as proposed, the turnaround time in them knowing that they are approved for treatment is much quicker. Depending on what services need to be authorized, each payer has different guidelines. You know, certain things you can get approved in three days or other things may be 14 days or longer in getting the authorization response back and some even longer than that. It all depends on the complexity of the services being rendered.

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Jennifer Cameron

But if the provider can write the order and it can go across and get authorized and provider get a response within the timeline that he is engaging with the patient family, then the patient already knows, you know, they're approved. And now I'm just getting scheduled as opposed to I want to get authorized and then I can get scheduled.

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Jennifer Cameron

So it will help thin that timeline out and patients would walk away with a better sense of understanding and security that this is I'm in agreement with my provider that these services is what I need. And oh, yes, I know my insurance company has approved it as well. And even on the reverse, if it denies the provider knows right then and there:

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Jennifer Cameron

Okay, we need to figure out how we move this case along the sometimes it all depends on the turnaround time with the payer. You may not find out for a week that the services you requested is now denied, and additional work needs to be done. So I think having the interoperability would be ideal. As long as these guardrails around it I think it would be beneficial not only to the patients but to the providers as they think about how they service care and knowing what services they can have that conversation with the family and move them through the process.

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Andrea Preisler

If I can just jump on to kind of piggybacking something that Jennifer mentioned. I think the idea of even if it is a denial immediately upfront, I think that's fantastic for the provider to have that information immediately as opposed to like you said, waiting, you know, a week, 2 or 3 weeks to receive that information so that the provider can then determine, okay, is an appeal the way to go here, or should we explore other treatment options?

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Andrea Preisler

I think it's critical and really important that the provider has that information as soon as possible. And I hope that this rule will do that.

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Tom Haederle

Great. Great point. David, what is your take on this this new rule from CMS? Do you think it will actually live up to its billing and simplify the process of getting a yes or a no in advance from insurers if a patient needs a medical procedure?

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David Jacobson, M.D.

I sure hope so. In our field, there's multiple different sets to get a patient for a transplant. So where we have to start with the blood work from the patient. So something called HLA typing to see if there's a match within the family. That generally requires a person in my department to submit paperwork to the insurance and then to hear back.

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David Jacobson, M.D.

And that can take about seven days. And it's generally approved because the indication is clear that the patient has the need for the need for transplant. But I can really see saving time and also see saving a lot of resources.

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Tom Haederle

We think nearly all providers would say the same thing that the prospective spending less time on red tape and more time, bedside time with the patient is a big step forward and a welcome one. Andrea, back to you for probably my final question here, administratively speaking, from your understanding of these changes in the CMS rule, will they be easy for a hospital or health system to implement?

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Tom Haederle

And do you foresee any bumps along the way?

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Andrea Preisler

Implementation will be challenging, but the good news for providers is that the onus of building out and implementing these APIs is entirely on the impacted payers of this final rule. So ideally, providers should not have to do too much work, right? The idea, though, that you know, this API that is being built in order to handle, you know, this enormous volume of work and taking what is currently a very manual process and making it fully electronic, the work can't be overstated.

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Andrea Preisler

It's a significant amount of work. We are involved in in that work and ensuring that, you know, the technology underlying this, regulation is appropriate and has the correct, you know, guardrails, as Jennifer mentioned earlier. So we are highly involved in that process. But again, the onus is on the payers to implement these APIs. So we are hopeful that it shouldn't be an enormous lift from the provider side.

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Tom Haederle

We are hopeful, indeed. We're near the end here and this is the any final thoughts or takeaways part of our chat. Anything that I didn't ask about that or anybody would like to contribute.

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Jennifer Cameron

I would just say, I think that if all of this comes together and, we're able to do that, I think it would really streamline so many of the processes. And I, again, to just reiterate that the outcomes will be better for the patients and families and even the providers as they try to navigate. I think the other piece of it is, as we look at the payers, some of these small payers, there may be challenges with those.

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Jennifer Cameron

Where they're not the big payers implementing about the Medicaid NCOs and those type of small payers, just as we, you know, just understanding how they're going to navigate all of that and move that along. But absolutely, I think it would be beneficial for all.

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Tom Haederle

Well, I know that's a widely shared sentiment, and I think we'll all be watching closely and hoping that this rule plays out in real life, real time, the way it's intended to, that it works as advertised. Thank you, Andrea, Jennifer and David for sharing your thoughts on this new direction from CMS about streamlining the prior authorization process to make life easier for patients and providers.

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Tom Haederle

And thank you all for joining us today for this Advancing Health podcast from the American Hospital Association. Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.