March 13, 2023

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-0057-P
7500 Security Boulevard
Baltimore, MD 21244

Re: Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program (CMS-0057-P)

Dear Administrator Brooks-LaSure:

On behalf of the undersigned 49 organizations representing more than 178,000 osteopathic physicians (DOs) and osteopathic medical students, thank you for this opportunity to comment on the Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule. We appreciate the work that the Centers for Medicare & Medicaid Services (CMS) has undertaken to address physician administrative burden and the agency’s commitment to pursing reforms that will improve care delivery and access.

As osteopathic physicians, we are trained in a patient-centered, whole-person approach to care. We believe policies should be tailored to empower physicians in partnering with patients to make treatment decisions that will result in the best outcomes. The prior authorization (PA) process places substantial time and cost burdens on physician practices, and care delays associated with PA often lead to serious adverse events among patients.

We commend CMS’ efforts to improve the PA process and support policy changes to require plans to support electronic prior authorization via a standards-based application programming interface (API). While we appreciate many of the reforms proposed in this rule, we also believe that several provisions may not fulfill CMS’ vision of reducing provider burden and could potentially have unintended consequences.

While this rule makes important strides in streamlining the prior authorization process and promoting transparency, we believe burden can be further alleviated by:

1. Driving automated processes for PA of drugs, items, and services, such as through the issuance of real-time decisions;

2. Limiting the application of PA and step therapy to drugs and services that are truly of concern for patient safety;

3. Preventing low-value PA policies that create burden and provide limited benefit to patient safety or appropriate utilization;

4. Ensuring that any PA policies are developed by experts in the relevant specialty using evidence-based criteria, and that adverse decisions or peer-reviews are conducted by relevant specialists; and

5. Ensuring physicians with strong records of proper documentation and approval for PAs are granted relief from requirements.

Our organizations generally support CMS’ effort to accelerate adoption of electronic PA and improve the process. However, we offer the following recommendations to strengthen the agency’s proposals and ensure that they have the intended impact of alleviating burden:

  • Imposing New Timeframes for Prior Authorization Decisions: We request the proposed timeframes of 1 week for standard requests and 72 hours for urgent requests be shortened to 72 hours for standard requests and 24 hours for urgent requests. This will ensure patients can receive timely care when they need it. Additionally, we urge CMS to consider establishing requirements that plans be capable of issuing real-time decisions for PA requests.
  • Establishing New Transparency Requirements: CMS’ proposal would require reporting of aggregate data points on approval rates, denial rates, average time elapsed to decisions, and other measures regarding prior authorizations. However, this reporting will have limited utility to beneficiaries shopping for plans, or providers contracting with payers, due to its lack of specificity. Requiring reporting based on specialty, therapeutic area, or service type classification will provide more meaningful information to patients and providers around how plans perform on various prior authorization metrics.
  • Requiring Issuance of Denial Reasons: While we appreciate CMS requiring plans to provide physicians and patients with denial reasons for denied PA requests, we urge the agency to adopt policy that will help reduce inappropriate denials. CMS should require potential adverse decisions to be reviewed by relevant specialists for the service prior to issuing any denial and require that PA requirements for items and services be based upon publicly available evidence or clinical guidelines.

Any change to improve prior authorization should be designed around the end goal of reducing physician administrative burden and allowing physicians to spend more time with patients. While many proposals in this rule will contribute to burden reduction, we strongly urge CMS to reconsider its proposal to create a new MIPS performance measure for electronic prior authorization under the promoting interoperability category.

The new electronic prior authorization measure is likely to create substantial burden for practices for the following reasons:

  • Health IT vendors are not required to certify their technology to an electronic prior authorization standard with ONC, creating concerns around the compatibility of these technologies with payers. Additionally, current implementation guides may not be ready for adoption as certification criteria by ONC. Before requiring physicians to report on use of electronic prior authorization, the technology must first be widely available, and technology must be demonstrated to effectively integrate into EMR workflows through real-world testing.
  • Many health IT vendors currently charge separately for electronic prior authorization functionality, and the cost associated with purchasing has been a substantial barrier to adoption for many small and independent practices. Practices must first be able to affordably adopt this technology before a requirement is established for its use. Otherwise, this requirement becomes a costly mandate for providers who are already facing Medicare payment cuts.
  • Requiring physicians to report the number of PAs submitted via a Prior Authorization Requirements, Documentation, and Decision (PARDD) API and the total number of PAs submitted among those that could be submitted via a PARDD API will be a substantial source of burden that contradicts the intent of this rule. Because physicians submit PAs via a range of modalities (i.e. EMR, payer portal, fax), it will be hard to track all PAs submitted. Certain functional deficiencies in existing electronic PA technology may result in physicians continuing to use other submission means, placing an inappropriate and unnecessary burden.

Compliance with the new MIPS measure will be particularly challenging for small and independent practices with limited financial and staff resources, who are already struggling in the midst of continued payment reductions. We recognize that CMS is seeking to catalyze electronic prior authorization adoption through this requirement. However, to fulfill the vision of this rule, CMS should reconsider any changes that would redirect physician time away from patients. Additionally, as electronic prior authorization becomes more commonplace, and the functionality becomes more affordable, practices will be incentivized to adopt this process which promises to free up resources and spend more time on patient care.

Our organizations greatly appreciate the effort and focus CMS has placed on improving PA and addressing burden across its recent rulemaking efforts. We look forward to continuing to work with CMS to improve timely access to care, to allow physicians to spend more time with patients, and to adopt PA reforms across insurance markets.

Sincerely,

American Osteopathic Association

Alaska Osteopathic Medical Association

American College of Osteopathic Emergency Physicians

American College of Osteopathic Family Physicians

American College of Osteopathic Internists

American College of Osteopathic Neurologists and Psychiatrists

American College of Osteopathic Obstetricians and Gynecologists

American College of Osteopathic Pediatricians

American College of Osteopathic Surgeons

American Osteopathic Academy of Orthopedics

American Osteopathic Academy of Sports Medicine

American Osteopathic Association of Prolotherapy Regenerative Medicine

American Osteopathic College of Anesthesiology

American Osteopathic College of Dermatology

American Osteopathic College of Physical Medicine & Rehabilitation

American Osteopathic College of Radiology

American Osteopathic Colleges of Ophthalmology & Otolaryngology-Head and Neck Surgery

Arizona Osteopathic Medical Association

Arkansas Osteopathic Medical Association

Connecticut Osteopathic Medical Society

Delaware State Osteopathic Medical Society

Florida Osteopathic Medical Association

Georgia Osteopathic Medical Association

Idaho Osteopathic Physicians Association

Indiana Osteopathic Association

Iowa Osteopathic Medical Association

Kansas Association of Osteopathic Medicine

Louisiana Osteopathic Medical Association

Maine Osteopathic Association

Massachusetts Osteopathic Society

Michigan Osteopathic Association

Michigan Osteopathic Association

Minnesota Osteopathic Medical Society

Missouri Association of Osteopathic Physicians and Surgeons

New Jersey Association of Osteopathic Physicians and Surgeons

New York State Osteopathic Medical Society

New Hampshire Osteopathic Association

North Carolina Osteopathic Medical Association

Ohio Osteopathic Association

Oklahoma Osteopathic Association

Osteopathic Physicians & Surgeons of California

Osteopathic Physicians and Surgeons of Oregon

Pennsylvania Osteopathic Medical Association

Rhode Island Society of Osteopathic Physicians and Surgeons

Tennessee Osteopathic Medical Association

Texas Osteopathic Medical Association

Utah Osteopathic Medical Association

Washington State Osteopathic Medical Association

Wisconsin Association of Osteopathic Physicians and Surgeons