CMS pitched prior authorization overhaul, but timeline remains uncertain

In December 2022, CMS pitched a rule it said would streamline the prior authorization process. But 10 months after closing public comment, it remains uncertain when — or if — the proposal will be finalized, KFF Health News reported Jan. 9. 

A CMS spokesperson told KFF Health News "there are no updates at this time." A post on CMS' website states the agency "is currently evaluating the public response for inclusion in a final rule." That public comment period ended March 13. 

Requirements for the rule proposed Dec. 6, 2022, would generally apply to Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program agencies, Medicaid-managed care plans, CHIP-managed care entities, and qualified health plan insurers on the federally facilitated exchanges.

CMS said the proposed rule would: 

  • Require the implementation of a Health Level 7 Fast Healthcare Interoperability Resources standard application programming interface to support electronic prior authorization. 
  • Require certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests. 
  • Add a new electronic prior authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System eligible clinicians under the promoting interoperability performance category.

The American Hospital Association in October urged CMS to quickly finalize the rule and said in particular it strongly supports the proposal to create interoperable prior authorization standards "to help address the significant burdens that prior authorization creates for patients and providers."

American Medical Association President Jesse Ehrenfeld told KFF Health News he hopes the rule, if finalized, would "move the needle a little bit," but added that "I think we're going to have to have regulatory relief from Congress." 

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