Providers press CMS to finalize prior authorization reforms to alleviate major administrative burdens

Several provider groups pressed Medicare officials Tuesday to install several proposed reforms to prior authorization, including mandating an electronic process for plans to approve requests. 

Leadership with the Centers for Medicare & Medicaid Services (CMS) held a roundtable Tuesday with medical groups on reforming prior authorization in government programs such as Medicaid managed care, Medicare Advantage and the Affordable Care Act’s exchange plans. The roundtable comes roughly a month after three proposed rules that aim to reform the process physicians say is a massive source of administrative burden. 

“These proposed actions will significantly streamline the prior authorization process for clinicians, improve the healthcare experience for people we serve and ensure they can access the care they need,” said CMS Administrator Chiquita Brooks-LaSure during a call with reporters Tuesday.

The agency proposed in a rule last year to mandate plans in government programs adopt electronic prior authorization systems by 2026. The goal is to streamline the process and quickly respond to physician requests for approval before the item or service can be delivered to the patient. 

The regulations would also require plans to hasten the approval of items or services that get routinely approved by the insurer in a bid to erase long wait times. If finalized, a payer has to decide on an urgent request within 72 hours and seven days for a nonurgent missive. 

Physicians that participated in the roundtable stressed for CMS to finalize the proposals. 

“It’s long past the time for CMS to hold health plans accountable for unconscionable delays and denials of care,” said Katie Orrico, senior vice president for health policy and advocacy for the American Association of Neurological Surgeons and Congress of Neurological Surgeons, in a statement. 

Surgeon General Vivek Murthy, M.D., who attended the roundtable, said participants had a sense of “optimism that this could be a chance for us to truly make a difference on an issue that has plagued clinicians and patients for many, many years.”

He cited a survey from the Medical Group Management Association that found 79% of medical groups indicated prior authorizations increased in the last year. 

Insurer groups have largely been in favor of shifting to electronic prior authorization, and the new proposals reflect demands for longer timelines compared to the Trump-era regulations. The rules replace a Trump-era regulation finalized in late 2020 before administrations changed hands. A big change from that regulation to the new proposal is the new reforms extend to Medicare Advantage plans.

Brooks-LaSure said this change was meant to reflect better consistency in agency regulations across all payers under the CMS umbrella. 

“It’s important that our rules are consistent, particularly as providers, clinicians, patients and increasingly health plans operate in all of the programs,” she said.