Source link <\/a><\/p>\n","protected":false},"excerpt":{"rendered":"
Add topic to email alerts
Receive an email when new articles are posted on
Please provide your email address to receive an email when new articles are posted on . “
data-action=”subscribe”>
Subscribe
We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: The American College of Rheumatology issued a letter in support of CMS\u2019 proposed rule to streamline prior authorization processes. However, the group said the rule does not go far enough in increasing transparency and interoperability. A new CMS proposed rule would reduce the burden of prior authorizations by further shortening payer decision timeframes and increasing transparency, but still does not go far enough, according to the American College of Rheumatology. Following up on its 2024 proposed rule reforming prior authorizations, which introduced a 72-hour timeframe for expedited requests and 7 days for standard requests, CMS\u2019 2026 proposed rule would tighten those windows to 24 hours for expedited requests and 72 hours for most others. In addition, the new rule would apply to payers across CMS programs, including Qualified Health Plan (QHP) issuers. The 2024 rule excluded QHP issuers from the shortened timeframe requirements.
Amanda Myers, MD, clinical assistant professor at the University of Chicago Pritzker School of Medicine, rheumatologist at Endeavor Health, and the ACR\u2019s Government Affairs Committee chair, told Healio that the 2026 proposed rule, issued by CMS on April 14, would also reduce administrative burdens by making it easier to transfer necessary documentation from electronic health records directly to the payer\u2019s system. It would additionally require all impacted payers to detail specific reasons for denying prior authorization requests for any drug. This provision would extend a similar requirement for non-drug services from the 2024 proposed rule. In a letter to CMS Administrator Mehmet Oz dated June 15, ACR President William F. Harvey, MD, MSc, FACR, commended these and other changes included in the new proposed rule. However, the letter also details several ways in which the ACR believes the rule could, and should, go further. For example, regarding the proposed rule\u2019s requirement that payers provide specific reasons for denials, the ACR letter states: \u201cWe urge CMS to provide further detail regarding what constitutes a \u2018specific reason\u2019 for a coverage denial. Vague denial reasons like \u2018medical necessity not met\u2019 or \u2018does not meet plan criteria\u2019 do not provide sufficient information.\u201d In addition, the letter notes that while the new rule would extend transparency and interoperability requirements to Medicare Advantage, Medicaid, CHIP and QHP plans on the federal marketplace, it leaves out QHP issuers on state-based exchanges. Healio sat down with Myers to discuss the importance of streamlining the prior authorization process, the particulars of the CMS proposed rule changes, and how ACR can continue to advocate for their patients to receive medications in a timely fashion. Healio: Why did the ACR feel the need to commend CMS on this document about prior authorizations? Myers: Reducing the burden of prior authorization processes on rheumatology practices is one of the ACR\u2019s core advocacy priorities. Prior authorization processes can cause major delays in patient access to care, sometimes leading patients to abandon treatment altogether. Prior authorization processes are also costly and time-consuming for physicians to navigate, especially for physicians working in private practice. This proposed rule would reduce the burden of prior authorization by shortening the decision timeframes in which payers must make prior authorization decisions, and requiring greater transparency around denials of care. Healio: What other parts of the CMS document prompted this letter? Myers: Additionally, by requiring payers to adopt a standardized application programming interface for prior authorization requests, the rule will allow smoother transfer of necessary documentation from electronic health records directly to the payer\u2019s system, minimizing administrative burden for the provider. Healio: Why is it so important to compress timelines for prior authorizations for patients with rheumatic and autoimmune diseases? Myers: Patients with rheumatic and autoimmune diseases require timely care in order to prevent severe inflammatory responses and permanent organ damage. Even brief delays in care can result in significant worsening of symptoms leading to decreased quality of life and disability. The delays imposed by prior authorization processes can result in life-threatening consequences for these patients. Many studies have found that delays in prior authorization processes are associated with disease exacerbation, preventable hospitalizations and longer hospital stays. For time-sensitive conditions, even short interruptions in treatment can result in dire clinical consequences. Healio: Why is it important to align prior authorization processes across payers? Myers: Aligning prior authorization processes across payers is a helpful step in minimizing administrative burden for physicians and their practices. Our expert clinicians need to focus on taking care of patients rather than navigating multiple sets of documentation requirements, submission portals and interfaces. Healio: What changes did CMS propose regarding denial of treatments, and what were the ACR\u2019s comments on those changes? Myers: The proposed rule requires payers to provide specific criteria for denials of care. The ACR supports this provision but requests that CMS provide further detail regarding what constitutes specific criteria. Denials that provide no information beyond \u201cmedical necessity not met,\u201d for example, do not provide sufficient information for physicians to determine what alternative treatment to pursue or how to appeal the denial. Denial criteria should be actionable and provide a clear path forward. Healio: What has CMS proposed regarding appeals process for prior authorizations, and what is the ACR\u2019s position? Myers: The proposed rule requires that denials include information on the appeals process. The rule also requires plans to report information about the rate of prior authorization decisions that are appealed and the results of appeals. The ACR is in support of these provisions that would increase transparency around the appeal process and make appealing a denial easier. Healio: How does the proposed rule address transparency in the prior authorization process? Is it enough? Myers: The proposed rule requires<\/p>\n","protected":false},"author":1,"featured_media":3008,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-3007","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/3007","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3007"}],"version-history":[{"count":0,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/3007\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/media\/3008"}],"wp:attachment":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3007"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3007"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3007"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
![\"healio](\"https:\/\/www.healio.com\/~\/media\/h5\/feature\/news\/publogos\/rheum.svg?la=en&h=44&w=141&hash=EBAD778B57889935130139D3FF110538\")
\n <\/div>\n<\/p><\/div>\n<\/p><\/div>\n