Under a new proposed rule, the Centers for Medicare & Medicaid Services (CMS) will require some payers to automate their prior authorization processes, respond more quickly, provide reasons for denials, and publicly report certain metrics, the agency announced on Tuesday.
If implemented, the proposed rule would mandate that "impacted payers" share prior authorization decisions within 72 hours for expedited requests and within 7 calendar days for "non-urgent" requests and require payers to include specific reasons for denials.
The proposal would also mandate that certain "eligible" providers and hospitals report metrics related to the adoption of electronic prior authorization.
Physician and medical groups cheered the agency's actions calling the proposal a "positive step forward."
Prior Authorization, Interoperability
Prior authorization requirements task providers with requesting approval from payers before patients can receive certain medical items or services.
The process is meant to ensure that the items are covered or are medically necessary, but many patients and providers see the process as burdensome, and for providers, costly and a major source of burnout. For patients, the process can disrupt and delay care -- in some cases, to the point where patients abandon treatments entirely, according to a CMS fact sheet.
To achieve these goals, CMS has proposed requiring impacted payers to "build and maintain a Provider Access API [Application Programming Interface] to share patient data with in-network providers with whom the patient has a treatment relationship."
The change would let providers know when a prior authorization is needed, what documentation is required, and allow providers to exchange requests and decisions from within the electronic health record (EHR) or a practice management system.
In addition to narrowing the decision window and requiring reasons for denials -- which the agency argued could improve communication between payers and providers and potentially help achieve "successful resubmissions" of requests in the future -- CMS proposed requiring impacted payers to publicly report certain prior authorization metrics annually.
Also, as a requirement of a previous finalized policy, under which payers were mandated to establish a Fast Healthcare Interoperability Resources (FHIR) Patient Access API, the agency is now proposing requiring regulated payers to include data about patient's prior authorization decisions "to help patients better understand their payer's prior authorization process and its impact on their care," the fact sheet noted.
In addition, CMS has proposed to require payers to exchange patient data -- which among other information would include prior authorization requests and decisions -- whenever a patient changes health plans, with the caveat that patients must opt into the data-sharing.
And for patients with concurrent coverage by two or more payers, impacted payers would be required under the proposed rule to make those patients' data available to the concurrent payer every quarter at a minimum.
Impacted payers, according to the fact sheet, would include:
- Medicare Advantage organizations
- State Medicaid and Children's Health Insurance Program (CHIP) fee-for-service programs
- Medicaid managed care plans and CHIP managed care entities
- Qualified health plan issuers on the federally facilitated exchanges
However, the proposed time frames would not apply to qualified health plan issuers on the federally facilitated exchanges, the agency noted.
Provider-Focused Measures
In addition to payer-focused policy changes the agency also proposed new measures to encourage "eligible hospitals" and critical access hospitals under the Medicare Promoting Interoperability Program, and for "eligible clinicians" under the Merit-based Incentive Payment System, to promote adoption of electronic prior authorization processes.
Specifically these providers, would be tasked with reporting the number of prior authorizations requested electronically through a Prior Authorization Requirements, Documentation and Decision API using data from certified EHR technology.
Tuesday's proposed rule also "formally withdraws" the previous CMS Interoperability and Prior Authorization proposed rule (85 FR 82586).
The agency also requested feedback regarding policies across the following areas:
- Barriers to adopting standards related to social risk data
- Ways to promote data exchange with behavioral health providers
- Ways Medicare Fee for Service can improve the electronic exchange of medical information between and among providers, suppliers, and patients
- Ways to strengthen prior authorization policies that impact maternal health outcomes
- Ways the Trusted Exchange Framework and Common Agreement can help promote changes in the newly proposed rule
The agency also specifically requested comments about the proposed time frame for expedited and standard (non-urgent) requests and asked whether a narrower decision window -- such as 48 hours and 5 calendar days for expedited and standard requests, respectively, for example -- would be preferred.
Stakeholders React
A number of physician and medical groups applauded the proposals.
"The average physician spends too much time completing prior authorizations -- taking time away from patients and potentially creating dangerous care delays," said American Academy of Family Physicians (AAFP) President Tochi Iroku-Malize, MD, MPH, MBA, in a press release.
"The rule is good news for family physicians and an important first step in alleviating burden and improving access to care," she added, noting, however, that more "comprehensive reform" is still needed to reduce the number of prior authorization requests that have to be processed.
The American Hospital Association (AHA) also applauded the agency's efforts to remove "inappropriate barriers to patient care" and was particularly pleased that Medicare Advantage programs were included in the scope of the rule.
"Prior authorization is often used in a manner that results in dangerous delays in care for patients, burdens health care providers and adds unnecessary costs to the health care system" wrote Ashley Thompson, AHA Senior Vice President, Public Policy Analysis and Development, in a press release.
Similarly, MGMA was "encouraged" by the proposal and the inclusion of Medicare Advantage plans, calling the "onerous methods" and current volume of prior authorization requests "unsustainable."
"An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals ... An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care," said Emily Dowsett, of MGMA, in an email to MedPage Today.
AAFP and AHA continued to press for passage of the "Improving Seniors' Timely Access to Care Act," which the AHA said would "codify these protections in law."
If implemented, the new policies would take effect Jan. 1, 2026, and the first set of proposed metrics would be reported March 31, 2026.
https://www.medpagetoday.com/practicemanagement/practicemanagement/102120
