Proposed CMS Payer Requirements Shouldn’t Burden Physicians, TMA Says
By Joey Berlin


A federal proposal that would require more transparency in insurers’ prior authorization denials in Medicaid and more sharing of such information with physicians could improve care delivery, but  also could result in more responsibilities on already overburdened physicians.

That was the message the Texas Medical Association delivered this week to the Centers for Medicare & Medicaid Services’ (CMS) in response to a proposed rule that would introduce new requirements for several types of payers, including Medicaid fee-for-service programs, Medicaid and CHIP managed care entities, and qualified health plans (QHPs) participating in the federal health insurance exchange.

CMS’ proposals would require Medicaid, CHIP, and QHP payers to:

  • Include information about a patient’s pending and active prior authorization decisions as part of the existing Patient Access Application Programming Interface (API); establish a privacy process for third-party apps to follow when retrieving patient data from the API; and build a Provider Access API to share claims and encounter data with physicians, as well as pending and active prior authorization data. Those regulations would take effect in 2023.
  • Give a specific reason for denying a prior authorization request. Most impacted payers would have 72 hours to respond to urgent requests and seven calendar days for standard requests.
  • Make educational resources available to physicians and other practitioners to describe in simple language how to request patient data using the Provider Access API.

In its letter, TMA strongly supported efforts to reduce excess prior authorizations within Medicaid and CHIP, as well as provide more transparency in the  process. It added that Texas Medicaid already implemented “many of the best practices” in CMS’ plan.

On the proposals regarding payers supplying information to patients, TMA said CMS “correctly places much responsibility” on payers to do so. However, TMA expressed concern “that payers, through coercive contracts will place additional responsibility on network physicians.”

“Any associated costs with implementing the proposals should not fall to physicians, and CMS should prohibit payers from using these proposals to place additional contractual demands on physicians,” TMA wrote. “If CMS moves forward with this proposal, TMA urges CMS to not burden physicians by requiring extra effort during the patient visit. These technologies should be designed and implemented in a way that delivers the information at the point of care in an easy-to-access and view format.”

TMA also said payers should increase transparency of prior authorization metrics, adding, “This will have significant potential to streamline information exchange between health care organizations/clinicians and payers.”

TMA’s letter asked CMS to expand its proposals to also cover Medicare Advantage plans. Medicine said extending the requirements to those plans would improve the electronic exchange of health information, whereas having different approaches to prior authorization and patient electronic access “wastes resources by forcing electronic health record developers to create multiple software programs, and it increases expenses as these costs and the burden of use are passed on to physicians and health care organizations.”

CMS’ rule proposal appeared in the Dec. 18, 2020, edition of the Federal Register.

Last Updated On

January 08, 2021

Originally Published On

January 08, 2021

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Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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