RISE examines the regulatory headlines of the week.

CMS proposed rule would streamline prior authorizations

The Centers for Medicare & Medicaid Services (CMS) on Thursday issued a proposed rule to improve the electronic exchange of health care data among payers, providers, and payers, and also streamline processes related to prior authorization to reduce burden on providers and patients.

“Prior authorization is a necessary and important tool for payers to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing administrative costs for the whole system,” said CMS Administrator Seema Verma in the announcement.

If finalized, Medicaid, CHIP and QHP payers would be required to build and implement Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard-enabled APIs that could allow providers to know in advance what documentation would be needed for each different health insurance payer, streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically directly from the provider’s EHR or other practice management system. While Medicare Advantage plans are not included in today’s proposals, CMS is considering whether to do so in future rulemaking.

The proposed rule would also reduce the amount of time providers wait to receive prior authorization decisions from payers—the rule proposes a maximum of 72 hours for payers, with the exception of QHP issuers on the FFEs, to issue decisions on urgent requests and seven calendar days for non-urgent requests. Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing.

CMS said these policies, taken together, could lead to fewer prior authorization denials and appeals, while improving communication and understanding between payers, providers, and patients. They are the result of numerous listening sessions with plans and providers aimed at crafting a new process that balances the need for greater efficiency and consistency in prior authorization and its important role in preventing fraud, abuse, and unnecessary expenditures. The agency projects the proposed rule would save between $1 billion and $5 billion over the next 10 years.

HHS proposes changes to HIPAA privacy rules

Also on Thursday, the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) proposed changes to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule  in an effort to remove barriers to coordinated care and reduce regulatory burdens on the health care industry.

HHS says the proposed changes would strengthen individuals’ rights to access their own health information, including electronic information; improve information sharing for care coordination and case management for individuals; facilitate greater family and caregiver involvement in the care of individuals experiencing emergencies or health crises; enhance flexibilities for disclosures in emergency or threatening circumstances, such as the opioid and COVID-19 public health emergencies; and reduce administrative burdens on HIPAA-covered health care providers and health plans, while continuing to protect individuals’ health information privacy interests.

OCR encourages comments from all stakeholders, including patients and their families, HIPAA covered entities (health plans, health care clearinghouses, and most health care providers) and their business associates, consumer advocates, health care professional associations, health information management professionals, health information technology vendors, and government entities. Public comments on the NPRM will be due 60 days after publication of the NPRM in the Federal Register. The NPRM may be viewed or downloaded from HHS’s website here.

CDC predicts the COVID-19 death toll in the US will reach 362K by January 2

The United States on Wednesday reported 3,054 deaths from COVID-19, a new record for single-day deaths from the coronavirus. But the death toll will likely become worse, said Robert Redfield, director of the Centers for Disease Control and Prevention. During an event hosted by the Council on Foreign Relations, Redfield said that even though a vaccine will likely be approved this week, the country will experience more deaths per day over the next 60 to 90 days than it had on 9/11 or Pearl Harbor, The Hill reported. The vaccine approval won’t have an impact for the next 60 days, though eventually he said the spread of the virus will slow as more people are vaccinated. He urged Americans to continue to follow precautions to prevent the spread of the deadly virus, including wearing a mask and avoiding indoor gatherings.