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CMS Rule Looks to Make Orthopedic Patient Care Access More Efficient

Healthcare News
CMS Rule Looks to Make Orthopedic Patient Care Access More Efficient

Having worked with orthopedic surgeons and practices throughout the US for decades, our team at HIS is well aware of the many pain points causing frustration for orthopedic practices. One area of frustration is prior authorization, which can delay patient care for days, weeks, or even months. The current policy put in place for prior authorization causes a significant hurdle for patients seeking care and the physicians looking to provide it. In an effort to improve the status quo, the Centers for Medicare & Medicaid Services finalized a rule to improve the prior authorization process in hopes of making the care process more efficient for spine surgeons and other physicians.

What are the Current Problems with Prior Authorization? 

Orthopedic surgeons are increasingly facing significant challenges related to prior authorization requirements from insurance payors. 

Here are the key issues they encounter:

1. Administrative Burden

Prior authorization (PA) adds a heavy administrative workload to orthopedic practices. Surgeons and their staff are required to spend considerable time completing forms, submitting documentation, and following up with payors to secure approval for necessary procedures, surgeries, imaging tests, and therapies. This diverts valuable time from patient care and leads to inefficiencies in the practice.

2. Delays in Patient Care

The approval process for prior authorizations can be lengthy, often causing delays in patient care. Orthopedic procedures that require immediate attention, such as joint replacements, fracture repairs, or advanced imaging (e.g., MRIs), may be postponed while waiting for authorization, negatively impacting patient outcomes and satisfaction.

3. Inconsistent Approval Criteria

Insurance payors often have inconsistent and opaque criteria for approving or denying prior authorizations. What qualifies for approval with one payer may not be approved by another, leading to confusion, denied claims, or delays in treatment. This inconsistency adds to the complexity of navigating the insurance landscape and can result in frustration for both surgeons and patients.

4. Financial Impact

Orthopedic practices may experience revenue loss due to denied prior authorizations. When procedures or treatments are delayed or denied, it can lead to missed opportunities for reimbursement. Additionally, surgeons may need to allocate extra resources to handle the appeals process, increasing operational costs.

5. Patient Dissatisfaction

Delays and denials due to prior authorizations can lead to patient dissatisfaction. Patients may perceive the surgeon or practice as inefficient or unresponsive when, in reality, it is the payer’s bureaucracy causing the delay. This can harm the practice’s reputation and patient retention.

6. Evolving and Complex Policies

Prior authorization requirements are continuously evolving, with new regulations and policies being introduced by both government and private payors. Keeping up with these changes requires significant effort, and failure to comply can lead to claim rejections or delays in approval.

7. Electronic Prior Authorization (ePA) Challenges

Although many payors are moving toward electronic prior authorization systems, integration with practice management software is not always seamless. This can result in technical difficulties, longer processing times, and additional frustration for staff managing the authorizations.

Prior authorization requirements have created a complex and burdensome process for orthopedic surgeons, impacting their ability to deliver timely care, manage operational efficiency, and maintain financial stability. Solutions like dedicated administrative support, automation tools, or external partnerships with revenue cycle management companies can help mitigate these challenges.

Calls for Improvement in the Prior Authorization Process

Healthcare providers of all kinds struggle with the issue of prior authorization, but orthopedic surgeons especially spine and neurosurgeons have been very outspoken about this common hurdle in patient care. Last year, Brian Gantwerker, MD of The Craniospinal Center of Los Angeles, spoke out about this issue, stating, “What we need more than ever is fair prior authorization practices to be put in place. Insurers have increasingly outsourced their authorization duties in order to save themselves money and to absolve them of arbitrary medical decisions by local and state rules. This has become customary and obstructionist and benefits only their shareholders. If Congress and HHS are serious about saving money, they need to stop letting insurers dictate the rules of engagement and stop blaming physicians who are fighting on behalf of their patients.”

Improving the Prior Authorization Process with CMS Rule

CMS’ 2024 rule will not go into effect until 2026. However, it contains several benefits for patients and surgeons – cutting the decision timeframe in half for some payors. According to Becker’s Spine Review, this rule will improve the prior authorization process by:

  • Requiring some payors to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests.
  • Requiring the inclusion of specific reasons for denying a prior authorization and the public reporting of prior authorization metrics. Affected payors will also have to implement a Health Level 7 Fast Healthcare Inoperability Resources prior authorization API to make electronic processing of requests more efficient. 
  • Updating API requirements to “increase health data exchange and foster a more efficient health care system for all.” API of affected payors must be expanded to include prior authorization information by January 1st, 2027. They will also need to implement a Provider Access API before this deadline. 

How to Improve the Prior Authorization Process for Your Practice

As mentioned above, CMS’ new rule regarding prior authorization will not go into effect until 2026. Until then, providers can take specific steps to streamline this process while continuing to provide comprehensive and personalized patient care.

  1. Identify Commonly Rejected Procedures and Refine Internal Processes
    • Regularly track and review procedures that are frequently denied by payers. Build a database of these common rejections, along with successful appeal strategies, to refine the submission process and reduce the likelihood of repeated errors.
  1. Establish Protocols for Consistently Documenting Prior Authorization Data
    • Implement a standardized checklist to ensure that all necessary documentation for prior authorizations is collected and consistently recorded in the patient’s medical record early in the care process. This minimizes delays caused by missing information and accelerates approval timelines.
  1. Educate Patients on the Insurance Company’s Role in Prior Authorizations
    • Inform patients that the responsibility for prior authorization approval rests with their insurance provider, not the practice. While doing so, maintain regular communication and transparency with patients by providing timely updates on the status of their authorization requests, so they feel supported throughout the process.
  1. Designate a Dedicated Staff Member for Handling Prior Authorizations
    • Assign a trained staff member to oversee and submit all prior authorizations, ensuring accountability and expertise in navigating payer requirements. Cross-train additional team members to cover this role when necessary and streamline the appeals process.
  1. Track and Monitor All Prior Authorization Requests Using Centralized Tools
    • Utilize a centralized tracking system or dashboard to monitor the status of all prior authorization requests. Automate follow-ups to ensure that decisions are received promptly and no requests are overlooked. This increases efficiency and prevents unnecessary delays.
  1. Standardize and Strengthen Rejection Appeals with Clear, Organized Documentation
    • Develop templates for submitting organized, concise, and well-supported appeal letters, tailored for different types of denials. Ensure that appeals include comprehensive clinical data and are articulated with specific language proven successful in previous cases.
  1. Collaborate with Other Providers to Address Insurance Authorization Issues
    • Network with other orthopedic practices and providers to share insights and experiences with problematic insurance payers. Leverage this collective knowledge to refine strategies for dealing with difficult authorizations and explore joint advocacy efforts through orthopedic associations to push for better payer processes.

These suggestions not only improve the prior authorization process but also integrate technology, communication, and collaboration to make the entire system more efficient and patient-centered.

Guidance and Support from HIS

At HIS, we help practices across the US prioritize their most important goal of providing high-quality, compassionate care to their patients. Our revenue cycle management, practice management and consulting services are designed to help your practice get things done more efficiently so you have more time to spend with your patients. When you work with HIS, you’ll gain a trustworthy partner for success as we empower your orthopedic or radiology practice with improved financial operations and increased practice efficiency. To speak to one of our experts about how HIS can help you, please contact us today!