The Centers for Medicare & Medicaid Services (CMS) on Tuesday announced a proposed rule that aims to alleviate clinicians’ concerns about burdensome prior authorization requests. It also addresses rules about electronic exchange of healthcare data.
The rule would require most insurers to send prior authorization decisions within 72 hours for urgent requests and 7 days for all others. The agency seeks comments on alternative deadlines, including 48 hours for expedited requests and 5 days for others.
CMS would also require insurers to report certain prior authorization metrics by posting them online each year. The proposed rules would apply to most Medicare and Medicaid patients.
If finalized, these prior authorization policies would take effect January 1, 2026, with the initial set of metrics proposed to be reported by March 31, 2026, CMS said.
The draft rule also proposes having clinicians report about their prior authorizations for medical items and services, excluding drugs, in connection with the Merit-based Incentive Payment System (MIPS) program.
Early reaction from medical organizations that have long lobbied for such changes appears positive.
“The average physician spends too much time completing prior authorizations — taking time away from patients and potentially creating dangerous care delays,” said Tochi Iroku-Malize, MD, MPH, president of the American Academy of Family Physicians (AAFP), in a statement. “The rule is good news for family physicians and an important first step in alleviating burden and improving access to care.”
Broad Initial Support
CMS will gather comments on the proposed rule in the weeks ahead through the Regulations.gov website.
In an email exchange with Medscape, AAFP explained that the proposed rule would have a wider sweep than does the Improving Seniors’ Timely Access to Care Act of 2021 (HR 3173).
That bill applies only to prior authorization in Medicare Advantage plans. CMS’s proposed rule would apply to Medicare Advantage, Medicaid, and the Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid and CHIP managed care plans, and qualified health plans on the federally facilitated exchanges, AAFP said.
The Improving Seniors’ Timely Access to Care Act of 2021 is a popular bipartisan bill that is supported by most members of the House of Representatives.
The House passed the bill in September on a voice vote, an approach used only for uncontroversial measures. But the Senate has not yet taken it up, and Congress faces a number of competing priorities, including the passage of bills needed to fund federal agencies, by the end of the year.
America’s Health Insurance Plans Chief Executive Matt Eyles said his organization’s Fast PATH demonstration project on prior authorization has shown that electronic processes can reduce administrative burdens, he said.
“This proposed rule would require clinicians and hospitals to adopt electronic prior authorization to meet certain quality measures, ensuring that we are all incentivized to work together for a better patient and clinician experience that improves satisfaction, efficiency, and affordability for everyone,” Eyles said.
The proposed rule also drew praise from the Better Medicare Alliance (BMA), an industry-backed advocacy group for Medicare Advantage plans.
The proposed rule appears to complement BMA’s “goals of protecting prior authorization’s essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community’s work streamlining this clinical tool,” Mary Beth Donahue, the group’s president and CEO, said in a statement.
Kerry Dooley Young is a freelance journalist based in Miami Beach. Follow her on Twitter @kdooleyyoung.