8 Modern Healthcare | August 19, 2019
Policy
requirements into the records. And
EHRs could also have documentation
requirements within the system to refer
to the CMS’ guidelines before submit-
ting prior-authorization requests.
The hospital-insurer battle over prior
authorization has simmered for years,
but this year it has been
highlighted as an issue for
congressional lawmakers
by provider lobbyists. And
they’ve made some prog-
ress. Reps. Suzan DelBene
(D-Wash.) and Mike Kelly
(R-Pa.) introduced a bill
that would establish an
electronic system for ap-
provals, cut the number of
preauthorizations for rou-THE TAKEAWAYHealth systems are
demanding that the
CMS set national
rules for how
insurers manage
prior authorization
and payment for pre-
approved claims in
Medicare Advantage.By Susannah Luthi tine services and eliminate them en-
tirely for “medically necessary services
performed during pre-approved surger-
ies or other invasive procedures.”
Insurers are watching for any potential
regulatory changes. The Blue Cross and
Blue Shield Association argued against
standardization, which it claims could
undermine how insurers’ tailor their
coverage for specific patient groups.
“While we support the goals of re-
ducing provider burden and improving
interoperability, we caution against ef-
forts to standardize criteria across the
industry,” Blues Vice President of Poli-
cy Kris Haltmeyer wrote in comments.
“Standardization could end practices
supporting appropriate variations in
member populations.”
In response to Patients over Paper-
work, Florida-based AdventHealth asked
the CMS to revise Emergency Medical
Treatment and Labor Act regulations.
EMTALA requires emergency depart-
ments to examine anyone who comes
through their doors. Hospitals and
emergency physicians complain about
unintended consequences of the man-
date, but there’s no sign policymakers or
regulators want to re-examine the law.
AdventHealth suggested the CMS
could expand its “emergency triage,
treatment and transport” model, which
lets ambulance care teams direct patients
to an ED or urgent-care clinic, to emer-
gency physicians or physician assistants.
“Patients presenting with cold symp-
toms, for example, could be triaged and
connected with a co-located urgent-care
clinic, saving them the expense of an ED
visit,” AdventHealth Vice President of
Advocacy Michael Griffin wrote in com-
ments. He added that the CMS could
consider additional guardrails to make
sure patients aren’t neglected.
He also recommended convening a
technical advisory group to review and
update EMTALA regulations. lHospitals push for streamlined MA
prior authorization rules
HOSPITALS AND HEALTH SYSTEMS
are demanding that the CMS set nation-
al rules for how insurers manage prior
authorization and payment for pre-ap-
proved claims in Medicare Advantage.
In response to the Trump adminis-
tration’s request for information on its
Patients over Paperwork initiative to
cut Medicare red tape, hospitals com-
plained that prior authorization is a
complicated system in which payment
isn’t guaranteed even if they follow all
the steps insurers lay out for them.
They want national standards so that
clinicians will know what they have to do
to get treatments approved regardless of
the insurer and to ensure they get paid.
“You follow the payer’s rules, you
think, ‘Wow that was an easy process,’
you thought you have checked all the
boxes to get the procedure paid, only to
be denied,” Laurie Pierce, director of pa-
tient financial services for 25-bed North
Valley Hospital in Whitefish, Mont., said
in written comments.
She also complained that the appeals
process is burdensome. On average she
has had to appeal unpaid Medicare Ad-
vantage claims at least three times.
For Dr. Timothy Dellit, chief medi-
cal officer for University of Washington
Medicine, the rules around prior-autho-
rization simply need to be clearer. Medi-
care insurers should state “when and
why pre-authorization is
not needed,” he said.
He also made two spe-
cific suggestions for a
technological overhaul
of the prior authorization
process. The CMS should
prod electronic health re-
cord vendors to allow cli-
nicians to enter codes for
coverage determinations
and prior-authorizationA 2018 American Medical
Association survey found that
65% of physicians had to wait at
least one business day for a prior
authorization decision from a
health plan.Under 1 hourA few hoursMore than a few hours, but
less than 1 business day1 business day2 business days3-5 business daysMore than 5 business daysDon’t knowEditor’s note: The AMA survey was not limited
to questions about Medicare Advantage plans.
Source: American Medical Association5%12%11%20%19%19%7%7%