CMS Proposed Rule Aims to Improve Prior Authorization Process

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ACP is advocating for finalization of the proposed rule, which includes a 72-hour time limit for decisions on urgent requests, seven-day limit for nonemergency requests

Jan. 27, 2023 (ACP) — The American College of Physicians is pleased that the Centers for Medicare and Medicaid Services (CMS) is seeking to streamline the prior authorization process and is urging Congress to make certain improvements permanent.

“The current process for prior authorization approval where health plans determine if a prescribed procedure, service, or medication is covered by a plan is especially burdensome,” Dr. Ryan D. Mire, president of ACP, wrote in a Jan. 18 letter to congressional leaders. “Payers, whether public or private, often have their own approaches, rules, and requirements for coverage. This process is costly for physician practices and can take time away from patient care.”

CMS recently proposed a new regulation to improve the prior authorization process for services and items (but not drugs) as of Jan. 1, 2026. The affected health plans include Medicare Advantage organizations, state Medicaid agencies, the Children's Health Insurance Program and federally facilitated marketplace health plans.

“The proposed rule would reduce the amount of time physicians have to wait for a decision from a payer on a prior authorization request. CMS has proposed to cap this time at a 72-hour limit for payers for urgent requests and seven days for nonemergency requests. This is twice as fast as the existing Medicare Advantage response time limit,” said Brian Outland, ACP director of regulatory affairs.

“CMS also would require payers to provide a specific reason when they deny a request,” he added. In addition, plans would be required to build application programming interfaces (APIs) for data exchange and streamline prior authorization by implementing HL7 Fast Healthcare Interoperability Resources standards to support an electronic process.

“ACP is pleased with the release of this proposed rule,” Outland said. “Our Patients Before Paperwork effort has continued to identify and prioritize the most burdensome administrative tasks, and at the top of that list is prior authorization. ACP commends the agency for taking these crucial steps, and we call on CMS to finalize this rule to ensure the strongest possible policies for ensuring physicians' ability to seamlessly provide care for their patients.”

ACP will provide comments to CMS on the proposed rule ahead of the March 13, 2023, deadline. “If finalized, effective Jan. 1, 2026, payers would need to have an API to facilitate the exchange of data electronically, among other requirements,” Outland said. “In getting to this point, there are a series of steps along the way, and we strongly encourage government and industry stakeholders to maintain open dialogue in seeing things through. The College looks forward to participating in these conversations and informing the implementation process.”

Meanwhile, ACP is lobbying Congress to reintroduce and swiftly pass the Improving Seniors' Timely Access to Care Act. “The House unanimously passed the bill last year, which would codify necessary improvements to prior authorization processes for Medicare Advantage organizations,” Outland said. “These things are a step in the right direction to relieving administrative burden, but there is much more work needed to permanently fix unnecessary prior authorization.”

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