Statement from the CQRC on the CMS Prior Authorization Final Rule


January 18, 2024

CQRC calls the final rule an important step, but says more should be done to protect patients

WASHINGTON, DC – “The Council for Quality Respiratory Care (CQRC) applauds the Centers for Medicare & Medicaid Services (CMS) for publishing the final rule advancing interoperability and improving prior authorization processes. The provisions in this final rule take an important step forward in addressing the barriers created by some health plans that use prior authorization to restrict access to critical, life-sustaining, specialized home respiratory equipment, such as non-invasive ventilators. This home-based equipment is essential to individuals with serious and sometimes end-of-life conditions including ALS, Restrictive Thoracic Disorders, and Chronic Respiratory Failure. We believe that greater transparency about the use of prior authorization, with coupled standardized rules for the processes around its implementation, will help to achieve a better balance than what exists today.

“As important a first step as the final rule is, more can, and should, be done to protect patients. For example, the CQRC recently asked CMS, in the rulemaking around the Contract Year 2025 Medicare Advantage proposed rule, to require data reported on utilization management tools be stratified so enrollees and their care partners can see the impact of these tools in relation to the specific conditions, or diseases, patients have, and treatment options on which they depend. Such information would empower these patients to make more informed choices when it comes to selecting the plan that is right for them.

“Moreover, we encourage CMS to apply the principles underlying the final rule to the Medicare program, especially in terms of the Medicare Administrative Contractors overseeing the Durable Medical Equipment benefit, known as the DME MACs. The current process for reviewing medical necessity of physician prescriptions for supplemental oxygen has been plagued by a lack of transparency and arbitrary denials linked to inadequate physician medical record notes. Just as CMS now requires commercial insurers to streamline their prior authorization process, the Administration should streamline the documentation requirements for supplemental oxygen. By requiring the DME MACs to use the clinical data element templates CMS has already created, that are available via its website, instead of relying upon doctors’ written chart notes, they are supporting future care decisions rather than spending time auditing functions. Moreover, CMS should require the DME MACs to establish electronic Application Programming Interfaces (APIs), just as it does in the final rule for commercial insurers, to allow physicians prescribing supplemental oxygen to submit the requests electronically, allowing them to use data from certified electronic health record technology (CEHRT). Finally, CMS should also institute a streamlined process with claims review timelines that are based on the same principles of ensuring timely access and coordination of care that underlie the timelines for 72-hour and 7 calendar day prior authorization decisions set forth in the final rule. 

“The CQRC supports balanced efforts to protect against abuse in the health care field while promoting patient care. We look forward to working with CMS to take the next important steps to leveraging advances in health information technology, physicians’ use of certified electronic health record technology, and the benefits of standardized data elements, along with streamlined processes that eliminate the need for paper and faxes to support medical necessity review for supplemental oxygen.”