Last week, APMA responded to the Centers for Medicare and Medicaid (CMS) proposed rule on interoperability standards and prior authorization for prescription drugs, which also included two requests for information related to health-care cybersecurity and durable medical equipment prosthetics and supplies (DMEPOS) prior authorization. APMA’s recommendations reflect APMA's ongoing commitment to reducing administrative burdens on physicians while ensuring timely patient access to medically necessary care.
Key recommendations to CMS included:
Require specialty expertise in reviews by ensuring prior authorization determinations are made by clinicians with relevant clinical knowledge, including podiatrists for lower-extremity care.
Accelerate decision-making by finalizing proposed timelines of 48 hours for standard requests and 24 hours for expedited requests.
Increase transparency and accountability through public reporting of approval rates, denial rates, response times, appeals outcomes, and other prior authorization metrics.
Require meaningful denial explanations to help providers efficiently appeal and resubmit requests when appropriate.
Advance gold carding policies that exempt providers with strong approval histories from unnecessary prior authorization requirements.
Support provider adoption of electronic prior authorization (ePA) through education, technical assistance, and flexible implementation policies.
Strengthen health-care resiliency by improving contingency planning, interoperability, and continuity of operations during cyberattacks and technology outages.
Reduce DMEPOS prior authorization burdens by standardizing requirements, expanding electronic workflows, creating expedited review pathways, and exempting routinely approved items where appropriate.
Address shortcomings in the WISeR model before using it to test additional prior authorization reforms.
To read the letter in full as well as all past advocacy comment letters, visit www.apma.org/commentletters. Contact the APMA Advocacy team at advocacy@apma.org with any questions or concerns.