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Medical, Insurer Groups Ask CMS to Not Implement Prior Authorization Provisions

Analysis  |  By Jay Asser  
   July 28, 2023

The organizations say the agency's proposed standards will be both conflicting and costly.

The American Hospital Association (AHA), the American Medical Association (AMA), the Blue Cross Blue Shield Association, and AHIP came together to urge CMS to not proceed with implementing proposed prior authorization (PA) standards that the organizations stated would be costly and conflicting.

In a letter penned to the federal agency, the groups argued that the provisions of the December 2022 Notice of Proposed Rule Making (NPRM) would be detrimental "due to conflicting regulatory proposals that would set the stage for multiple PA electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate."

The organizations shared their concern that the provisions would establish two different sets of PA standards. While the NPRM would require a combination of both X12 and Health Level 7 (HL7) standards, the Advancing Interoperability and Improving Prior Authorization NPRM would require health plans to offer HL7 Fast Healthcare Interoperability Resources (FHIR)-based application programming interfaces to support electronic PA information exchange.

Additionally, the groups highlighted that efforts to automate PA-related data exchange use HL7 FHIR implementation guides.

"This outcome would directly counter the foundational principles of the original HIPAA administrative simplification statute and regulations (i.e., adoption of electronic standards to support uniform communication between providers and all health plans); cause widespread industry confusion; slow implementation; and be enormously expensive for both health plans and providers, as they would undoubtedly need to implement technologies to meet the requirements of both NPRMs," the organizations wrote.

Prior authorization reforms have garnered widespread support and the need to streamline the administrative process is clear. A recent poll of 1,001 practicing physicians by AMA revealed that 89% of respondents felt PA had a negative impact on patient clinical outcomes.

However, enforcing a singular set of standards would be the most efficient way to get health plans to comply, resulting in less waste of resources and more timely care for patients.

Jay Asser is the contributing editor for strategy at HealthLeaders. 


In a letter to CMS, the American Hospital Association, the American Medical Association, the Blue Cross Blue Shield Association, and AHIP united to make the case against proposed prior authorization standards.

The groups stated that the provisions of the December 2022 Notice of Proposed Rule Making would create two sets of standards that would slow implementation and add unnecessary costs.

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