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When it comes to the U.S. Centers for Medicare & Medicaid Services, chances to effect significant change don't come around that often — and when they do, opportunities shouldn't be passed up. That's precisely the scenario the physical therapy profession now faces in a crucial area in need of reform: prior authorization. APTA is urging members and supporters to make their voices heard before a looming March 13 deadline.

"A Real Difference for Providers"
In three separate proposed rules, CMS lays out significant changes to prior authorization practices across a broad range of programs including state Medicaid and Children's Health Insurance Program fee-for-service plans, Medicaid managed care plans, CHIP managed care entities, Qualified Health Plan issuers in the federal ACA insurance exchanges, and Medicare Advantage. The trio's headliner is a sweeping provision that would significantly increase transparency and streamline the prior authorization process, while related but smaller-scale rules would address current inconsistencies around how data is exchanged and establish clinician advisory committees to inform utilization management in Medicare Advantage organizations.

Provider concern over the administrative burden associated with prior authorization isn't new, and reining in its misuse has been a constant feature of APTA's advocacy efforts. Over the years, CMS has acknowledged that the issue needs to be addressed, but this is the closest the agency has come to taking action (CMS proposed reforms to prior authorization in 2020 but never acted on them).

"It's difficult to overstate the importance of these proposed rules, particularly the large-scale rule that affects multiple programs," said Kate Gilliard, APTA's director of health policy and payment. "While it's true the proposals won't completely eliminate prior authorization, CMS is offering up changes that will make a real difference for providers — particularly PTs, who are typically saddled with more prior authorization than the average clinician. That's why it's so important that the profession seize this critical opportunity and make its voice heard."

In addition to the extensive proposed rule, two more modest rules also could improve the prior authorization landscape if adopted. One would establish safeguards and transparency in the prior authorization practices of Medicare Advantage organizations, including the establishment of utilization management committees with a significant clinician presence that would provide more frequent review of UM policies in MA. The second would adopt a clear set of standards for electronic data exchange related to prior authorization, laying the groundwork for transparency and uniformity, and bringing an end to the use of outdated, more manual processes for data transmission including those using paper, mail, fax, and phone.

The Key: Provide Personal Perspectives (by March 13)
CMS is continuing a shift in how the agency looks at comments on a proposed rule, away from tallying up templated form letters and toward an emphasis on the personal insights of individual providers. While comments from APTA and other stakeholder groups will continue to matter, the key to adoption of the rules may well rest in the hands (and keyboards) of individual clinicians who provide comments by the March 13 deadline.

"CMS really does take these individual letters into account," said Rachel Miller, MPH, APTA regulatory affairs specialist. "And the fact that so many PTs and their patients have been adversely affected by excessive prior authorization requirements means that the profession could provide significant insight that would really help push these rules over the goal line." 

While it's true drafting your own letter might not be as simple as clicking on a form or fowarding an email, it's easier than you might think: APTA offers guidance on how to write a comment letter to CMS, including this 5-minute video that can help get you started.

The emphasis on personal letters doesn't mean the more automated options for advocacy have gone away: members and supporters can still quickly create templated communications on the proposed rule by visiting the APTA Patient Action Center.

Next Steps: Understand What's Being Proposed and Where to Focus Your Energy
While the proposed rules are linked, APTA recommends that supporters focus primarily on the far-reaching rule around prior authorization. Read this APTA article on the proposed rule, the CMS fact sheet on the changes, and even the proposed rule itself. Then, get ready to write your letter by reviewing APTA guidance.

Now's the time to get started. Deadline for comments is March 13.

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