The Centers for Medicare & Medicaid Services (CMS) have recently proposed changes to prior authorization requirements for various medical services. The proposed rule change intends to streamline prior authorization processes to reduce administrative burden and improve access to care. The proposed rule change promotes the adoption of electronic prior authorization (ePA) tools to automate the prior authorization process. Banjo Health is the leading innovative prior authorization automation platform for medical and pharmacy PAs, and this white paper aims to provide health insurance and pharmacy benefit management (PBM) executives with a comprehensive overview of the proposed CMS rule change and how Banjo Health can help them prepare for the change.
Overview of Proposed CMS Rule Change and Its Impact on Health plans:
The proposed CMS rule change aims to reduce the administrative burden on healthcare providers and improve patient access to care by streamlining the prior authorization process. The rule change would apply to:
- Medicare Advantage (MA) plans
- Medicaid Managed Care Organizations (MCOs)
- Qualified Health Plans (QHPs) participating in federally facilitated exchanges.
The new proposed rules will have a significant impact on health plans. Here are some key ways in which the ruling will affect health plans:
Administrative Burden Reduction: The CMS rule change aims to reduce the resources needed to process PA requests by promoting the use of medical automation, like ePA, and quality outcomes through increased system interoperability and data collection. Health plans will be required to implement these tools to automate the prior authorization process for certain medical services. This automation will significantly reduce manual tasks, paperwork, and phone calls associated with prior authorization, allowing health plans to streamline their operations and allocate resources more efficiently.
Improved Provider and Patient Experience: In addition to reduced administrative burden, the promotion of ePA automation and initiatives such as DaVinci Project and HL7 FHIR, CMS is hoping to improve the rate at which patient data is shared, systematizing the PA process across all health plans. With ePA tools and automated workflows, health plans can reduce the time and effort required for prior authorization, resulting in faster approvals and increased access to care. Providers will spend less time on administrative tasks and more time focusing on patient care, leading to improved satisfaction and better overall healthcare outcomes.
Enhanced Transparency: The CMS ruling emphasizes the importance of transparency in the prior authorization process. Health plans will be required to provide clear and easily accessible information to providers and patients regarding prior authorization requirements. This includes maintaining a comprehensive list of services that require prior authorization, sharing clinical criteria for authorization, and providing estimated time frames for approval or denial. Improved transparency will enable healthcare providers to make informed decisions and patients to have a better understanding of the authorization process.
Opportunities for Process Optimization: As health plans prepare for the implementation of the CMS ruling, they will have the opportunity to evaluate their current prior authorization processes and identify areas for improvement. This evaluation can include a review of existing ePA tools and the potential for expanded use, as well as an assessment of clinical criteria to determine if any unnecessary requirements can be eliminated. By optimizing their processes, health plans can achieve greater efficiency and reduce the burden on both providers and patients.
The Impact of the Proposed CMS Rule Change on Healthcare Providers:
The proposed CMS rule change has the potential to significantly impact healthcare providers. Here are some key ways in which the ruling will affect healthcare providers:
Reduced Administrative Burden: The streamlined prior authorization process facilitated by the CMS ruling will lead to a significant reduction in administrative burden for healthcare providers. With ePA tools and automated workflows, providers can spend less time on administrative tasks and more time focusing on patient care.
Increased Access to Care: The streamlined prior authorization process will also lead to increased patient access to care. With faster approvals and reduced administrative burden, providers can more easily provide necessary medical services to their patients.
Improved Clinical Decision-Making: With the use of clinical decision support tools, healthcare providers can make more informed clinical decisions during the prior authorization process. This will result in better healthcare outcomes for patients.
How Health plans Can Prepare to Implement the Proposed CMS Rule Change:
Health insurance and PBM executives can prepare for the proposed CMS rule change by taking the following steps:
Evaluate Current Prior Authorization Processes: Health plans should evaluate their current prior authorization processes to identify areas that can be improved to meet the newly proposed standards. This evaluation should include an assessment of the current use of ePA tools and the potential for expanded use of these tools.
Identify Services That Require Prior Authorization: Health plans should identify services that require prior authorization and review the clinical criteria for prior authorization. This review will help health plans determine if there are opportunities to reduce unnecessary prior authorization requirements.
Develop a Plan for Implementation: Health plans should develop a plan for implementing the proposed CMS rule change. This plan should include timelines for implementing ePA tools, developing streamlined prior authorization processes, and improving transparency.
Proactively Engage with Providers: Health plans should work closely with healthcare providers to ensure a smooth transition to the new prior authorization process. This may include providing training on new ePA tools and workflows, as well as offering support and information to providers during the transition.
Banjo Health: Your Partner in Prior Authorization Transformation
Banjo Health is uniquely positioned to support health insurance and PBM executives in preparing for the proposed CMS rule change and addressing the challenges associated with prior authorization. Here's how Banjo Health can help health plans and providers address the impacts and opportunities stemming from the proposed rule change.
BanjoPA, Banjo Health's cutting-edge prior authorization workflow automation platform, allows you to automatically ingest, manage, and respond to PA requests quickly and confidently, freeing up resources and significantly reducing the administrative burden. With BanjoPA, you can streamline your prior authorization process, eliminate manual tasks, paperwork, and phone calls, and allocate resources more efficiently.
Banjo Health allows you to reduce the time and effort required for prior authorization, resulting in faster approvals and increased access to care. BanjoPA's automated workflows enable providers to spend less time on administrative tasks and more time focusing on patient care, leading to improved satisfaction and better overall healthcare outcomes.
Banjo Health makes appeals and compliance a snap all recommendations and decisioning is completely auditable with step-by-step reasoning of why a specific recommendation was given.
BanjoPA's comprehensive prior authorization management system provides clear and easily accessible information to providers and patients regarding prior authorization requirements. BanjoPA maintains a comprehensive list of services that require prior authorization, shares clinical criteria for authorization, and provides estimated time frames for approval or denial. With BanjoPA, you can improve transparency and enable healthcare providers to make informed decisions and patients to have a better understanding of the authorization process.
Banjo Health's suite of prior authorization workflow automation solutions, including BanjoPA and Composer, can help health plans optimize their processes. BanjoPA's automated workflows eliminate manual tasks and paperwork.
Composer's AI-powered decision tree creation capabilities enable users to rapidly create accurate decision trees in minutes rather than hours. By optimizing their processes with Banjo Health's solutions, health plans can achieve greater efficiency and reduce the burden on both providers and patients. Composer uses Optical Character Recognition (OCR) and Natural Language Processing (NLP)to quickly and accurately detect the decision points within a specific therapy’s clinical criteria and instantly maps out a draft decision tree. The intuitive UI gives clinicians the ability to review and edit quickly and easily.
The proposed CMS rule change presents a transformative opportunity to streamline the prior authorization process and enhance patient access to care. Health insurance and PBM executives can leverage Banjo Health's suite of prior authorization workflow automation solutions and clinical decision support tools to reduce administrative burdens, optimize processes, and deliver superior care to their members.
If your organization wants to know how Banjo Health can help you meet the upcoming CMS changes, reduce administrative burden while optimizing process enhancements, and provide better patient care, please schedule a demo as soon as possible. We want to show your organization how our cutting-edge solutions can automate and streamline the prior authorization process, drastically reducing time delays for patients to receive care and improving member satisfaction while freeing up organizational resources.
