AAFP to CMS: Cut Prior Authorization to Preserve Programs

Academy's RFI Responses Call on Agency to Align Rules With Reality

December 03, 2019 02:03 pm News Staff

The Academy recently pushed CMS for regulations that would reduce physicians' administrative burden and financial risk while ensuring higher-quality medical outcomes and improved interoperability.

[integrity written with blue marker]

"The AAFP strongly supports streamlining prior authorization requirements and reducing administrative burden in all health care programs -- both public and private," said the Academy in one of two Nov. 20 letters calling on the agency to tighten its focus on patient care.

Both letters addressed the integrity of the nation's public health care programs -- one specifically focusing on the future of such programs(5 page PDF) and the other on technology used to support them.(3 page PDF) They were sent to Alec Alexander, deputy administrator and director of CMS' Center for Program Integrity, in response to a pair of requests for information: "The Future of Program Integrity"(www.cms.gov) and "Using Advanced Technology in Program Integrity."(www.cms.gov) Both letters were signed by AAFP Board Chair John Cullen, M.D., of Valdez, Alaska.

Regarding the future, the agency's RFI had posed questions about fraud, waste and abuse in value-based payment programs.

The Academy's response was straightforward: It's time to align the rules with reality.

The AAFP urged CMS to "focus more on outcomes related to quality and utilization and less on procedural safeguards" -- an approach the Academy said would be "more consistent with the guiding principle of choice and competition in the market based on quality, costs and outcomes than the current approach of subjecting beneficiaries and physicians to increasingly stringent forms, coverage criteria and documentation requirements."

To wit: prior authorization.

"Onerous and unnecessary prior authorization requirements top the list of physician complaints on administrative burdens," the Academy said. "This uncompensated work for physicians and staff translates into increased overhead costs for practices, significantly reduced time spent with patients, disruption of workflows that result in costly inefficiencies, and delayed care and worse outcomes."

Whereas Medicare's program integrity efforts in fee-for-service environments have centered on guarding against overpayment and unnecessary utilization, the Academy pointed out that in value-based models, "CMS and other payers are increasingly asking physicians to take financial risk for the services they provide and, in some cases, the total cost of care for attributed patients."

"The program integrity strategy needs to change accordingly," the Academy advised.

The letter went on: "For instance, instead of relying on prior authorizations and other tactics that seek to restrain the volume of services rendered, CMS needs to rely on tactics that ensure appropriate patient attribution" while also ensuring that "patients receive the services needed for positive health outcomes."

Elsewhere in its RFI, CMS had asked how it could "better connect ordering physicians, rendering providers and suppliers with respect to their responsibility to provide proper documentation."

Again, the Academy had a ready answer: Support regulations proposed by the Office of the National Coordinator for Health IT. Specifically, CMS should require use of the Fast Healthcare Interoperability Resources standard, which would ease the exchange of data.(2 page PDF)

Likewise, the AAFP's second letter on the impact of advanced technology on program integrity advocated for regulations that would reduce administrative complexity.

CMS had asked about the potential uses of artificial intelligence and machine learning in streamlining medical data review and determining coverage compliance.

Such tools, the Academy answered, aren't here yet -- but they shouldn't encumber physicians when they arrive, especially if CMS is involved in their deployment.

New technology must be able to be integrated into physicians' workflow without requiring physicians to enter any additional data, the Academy said, and it must be affordable.

"It would also need to be tied to some specific CMS policies that clearly defined how the tool could be used," the letter went on. "Additionally, if the tool is not highly accurate or if there is no payment assurance based on the results of the tool, adoption is likely to be low."

Related AAFP News Coverage
AAFP Guides CMS on Administrative Simplification Efforts
(8/13/2019)

AAFP Advises CMS on Making Value-based Model Work for FPs
(6/5/2019)