New CMS rules ‘a major win’ on prior authorizations, but more action is needed

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Advocates for quicker care joined the organizations responding to new Medicare rules that aim to speed up the prior authorization process and increase data sharing in medicine.

On Jan. 17, 2024, the U.S. Centers for Medicare & Medicaid Services (CMS) announced CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). There will be new requirements starting in 2026 for payers to have quicker turnaround on requests for patient care, and more data sharing among payers and physicians and other clinicians.

The new rules generally got favorable responses almost immediately, with additional reactions coming later that day. Health care organizations called for Congress to push for further reforms that could improve care for patients and paperwork for physicians and other clinicians.

Lawmakers react

Legislators including some physicians in Congress issued a joint statement calling the changes “a major win for seniors and their families.” The group included Sen. Roger Marshall, MD (R-Kansas), Sen. Sherrod Brown (D-Ohio), Sen. John Thune (R-South Dakota), Sen. Kyrsten Sinema (I-Arizona), Rep. Suzan DelBene (D-Washington), Rep. Mike Kelly (R-Pennsylvania), Rep. Ami Bera, MD (D-California), and Rep. Larry Bucshon, MD (R-Indiana).

“These new protections will make a big difference in helping seniors access the medical care they are entitled to without unnecessary delays and denials due to prior authorization,” the statement said. “This will also enable health care providers to focus on delivering better care rather than wasting hours on the phone with insurance companies. While CMS could have gone further, these changes will help bring the antiquated prior authorization system into the 21st century with commonsense changes like a streamlined approval process and increased transparency.

“Now, Congress must act to cement these gains into law by passing the overwhelmingly bipartisan, bicameral ‘Improving Seniors' Timely Access to Care Act’ to ensure seniors are getting the care they’re entitled to and reduce hours of unnecessary burden for physical practices and hospitals,” they said.

Faster reviews needed

AMGA, a trade association for medical group management, noted the data-sharing requirements for payers do not apply to commercial insurers. AMGA supports legislation drafted by Sen. Markwayne Mullin (R-Oklahoma) that would require all payers to share claims data with providers. That rule was included in an amendment to Senate Bill 1339, known as the “Pharmacy Benefit Manager Reform Act.”

AMGA also wants faster turnaround times on prior authorizations – 48 hours for standard requests and 24 hours for urgent ones, with the designation of automatic approval if health insurance plans miss the deadlines.

“These timelines need to be much shorter,” AMGA President Jerry Penso, MD, MBA, said in a statement. “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.”

‘Recovery Plan for America’s Physicians’

American Medical Association (AMA) President Jesse M. Ehrenfeld, MD, MPH, said the new CMS rules were important reforms.

The “final rule requires impacted plans to support an electronic prior authorization process that is embedded within physicians’ electronic health records, bringing much-needed automation and efficiency to the current time-consuming, manual workflow,” Ehrenfeld said. “The AMA also appreciates that the rule will significantly enhance transparency around prior authorization by requiring specific denial reasons and public reporting of program metrics as well as requiring that prior authorization information be available to patients to help them become more informed decision makers.

AMA commended the administration of President Joe Biden for the prior authorization reforms, Ehrenfeld’s statement said.

“The AMA looks forward to continuing to work with CMS on this critical issue, including expanding these improvements to drug prior authorization,” he said. AMA has included prior authorization reform in its “Recovery Plan for America’s Physicians,” and “the AMA is working on every front to tackle prior authorization challenges so physicians can focus on patients rather than insurance obstacles to medically necessary care,” Ehrenfeld said.