Standardized, Streamlined Processes Key to Implementing Electronic Prior Authorization

January 6, 2021

On December 23, 2020, ASCO submitted comments to the Centers for Medicare & Medicaid Services (CMS) in response to the Reducing Provider and Patient Burden and Promoting Patients' Electronic Access to Health Information proposed rule. This rule builds on the CMS Interoperability and Patient Access final rule and would require Medicaid and Children’s Health Insurance Program (CHIP) managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plan (QHP) issuers on federally facilitated insurance exchanges to improve the electronic exchange of health care data, and streamline processes related to prior authorization.

The Association for Clinical Oncology (ASCO) does not support any use of prior authorization that could prevent patient access to cancer care. However, ASCO’s comments—which include recommendations for implementing the rule—assert that correctly implementing the proposed rule could help standardize and streamline the prior authorization process, reduce delays in care, and alleviate some of the administrative burden of the existing process.

Specifically, ASCO recommends that CMS:

  • require payers to include the same information regarding pending or active prior authorizations for prescription drugs and/or covered outpatient drugs as for other items and services discussed in the rule.
  • examine the impact of prior authorization requirements on access to care and clinical outcomes by developing a single set of standards for prior authorization policies; these standards should then be incorporated into the payer’s star rating.
  • require payers to establish a Documentation Requirement Lookup Service application programming interface, which would include information on the list of services and items for which prior authorization is required and details on documentation requirements. This could improve efficiency, reduce the number of unnecessary requests, and minimize follow-up.
  • require specific documentation of the reason for a denial to enable physicians or beneficiaries to appeal appropriately and efficiently.
  • establish efficient and responsive prior authorization request processes, including completion of review/decision on standard requests, appeals, and expedited reviews for oncology within 48 hours.
  • reduce physician burden and help ensure that patients do not find themselves without access to potentially life-saving therapies by having prior authorization approval follow patients should they switch plans and/or payers.

Read the full letter.

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