AMGA Priority on Patient Data Sharing Finalized in CMS Rule
A win for coordinated patient care today with CMS final rule on Interoperability and Prior Authorization. Access to claims, encounter, and other patient data has been a long-standing AMGA priority.
Calls on Congress to Expand to Commercial Payers
Alexandria, VA - Today’s Centers for Medicare & Medicaid Services (CMS) final rule on Interoperability and Prior Authorization reflects a longstanding AMGA priority and will help ensure providers have access to claims, encounter, and other patient data. AMGA and its member providers recognize the importance of timely access to patient data to deliver the best possible care. Medical groups and health systems need current patient data to ensure appropriate treatment across the care continuum. Such data offers providers a complete picture of a patient’s medical history – the tests, screenings, vaccines, and medicines – and will help eliminate redundancy and improve coordination of care no matter where the patient receives services.
“This is a welcome first step in ensuring providers have the most comprehensive data set available about their patients,” said Jerry Penso, MD, MBA, AMGA president and CEO. “Quickly sharing data ensures appropriate care is provided, and just as importantly, any unnecessary or duplicative care is avoided. Patients will get the care they need and avoid the care they don’t.”
Under the final rule, public payers, such as Medicare Advantage and health plans offered on federally run Affordable Care Act exchanges, will be required to share data with in-network or enrolled providers beginning in 2027. AMGA recommended payers be required to make the data available to all providers, regardless of whether the provider is under contract or enrolled with the payer. CMS will consider a requirement to share patient data with out-of-network providers in future rulemaking. AMGA recommends CMS finalize such a requirement as soon as feasible.
Today’s rule does not apply to commercial insurance plans. AMGA strongly recommends Congress build on CMS’ example and apply the data-sharing requirements across the health insurance sector. By requiring all payers to share claims data with providers, every patient will benefit from providers who are as informed as possible about past health conditions, current treatments, and, crucially, any gaps in care. AMGA strongly supports legislation drafted by Sen. Markwayne Mullin (R-OK) that requires plans to share this data. This legislation was included in an amendment to S. 1339, the Pharmacy Benefit Manager Reform Act. We urge Congress to pass this much-needed data-sharing provision.
Prior Authorization Timeframes Unworkable
AMGA appreciates CMS recognized the flaws in the current prior authorization process, which results in obstacles to patient care. While the rule attempts to streamline the prior authorization process, the timelines as finalized do not reflect how care is delivered. Under the final rule, plans must issue a prior authorization decision within 72 hours for expedited (or urgent) requests and within 7 days for a standard request.
“These timelines need to be much shorter,” Penso said. “There is nothing expedited about three days. Slow-moving prior authorization decisions leave patients in limbo and create a cascading effect of backlogs in the system.”
AMGA specifically recommended CMS require plans to respond to prior authorization requests in a much shorter timeframe: 48 hours for standard requests and 24 hours for urgent ones. In addition, AMGA recommended requests be deemed approved if plans missed the deadlines.
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About AMGA
AMGA is a trade association leading the transformation of healthcare in America. Representing multispecialty medical groups and integrated systems of care, we advocate, educate, innovate, and empower our members to deliver the next level of high performance health. AMGA is the national voice promoting awareness of our members’ recognized excellence in the delivery of coordinated, high-quality, high-value care. More than 175,000 physicians practice in our member organizations, delivering care to one in three Americans.
AMGA represents medical groups and integrated systems of care. Its diverse membership includes multispecialty medical groups, integrated delivery systems, accountable care organizations, and other entities committed to improving healthcare outcomes. AMGA advocates for the formation of innovative, clinically integrated systems of care that advance population health, enhance patient experience, and reduce healthcare costs. For more information, please visit www.amga.org.