The American Medical Association (AMA) said Monday it “welcomes” updated guidance from the U.S. Centers for Medicare and Medicaid Services (CMS) that strengthens federal transparency requirements for prior authorization.
The country's largest physician organization had documented concerns and recommended specific corrective actions to the agency in May (PDF), following the group's review of how 15 Medicare Advantage contracts were implementing transparency provisions of the CMS Interoperability and Prior Authorization final rule.
The 2024 final rule requires payers to publicly post prior authorization requirements and outcomes, with a three-day deadline for urgent requests and a seven-day deadline for standard requests.
“The AMA documented these practices, brought them to CMS, and the agency acted,” the organization said. “The AMA is grateful for the updated guidance.”
The updated metrics reporting framework (PDF) clarifies that posting required metrics only through password-protected portals or “other locations that cannot be reached through ordinary navigation from the payer’s public-facing website” does not satisfy the rule’s “publicly accessible” requirement.
The agency now also specifies that plans must publicly identify all medical items and services requiring prior authorization and identify omission of entire categories of care from disclosures. Moreover, it clarifies disclosures must be understandable and turnaround-time metrics must include a unit of time.
AMA President Willie Underwood III, M.D., said in a statement the agency has “taken an important step” with the new guidance towards making prior authorization information “more transparent and usable.”
“But the work is not finished. Patients and physicians need information that is accurate, accessible, understandable and comparable across health plans,” Underwood said. “You shouldn’t have to be a rocket scientist to figure out what the insurance companies are doing. The AMA will continue working with CMS to make sure transparency requirements actually deliver transparency.”
The organization urged CMS to address what it says are “several remaining gaps” in its transparency framework, including:
- Defining prior authorization broadly enough to “capture rebranded practices”
- Making information available at the point of enrollment
- Standardizing prior authorization reporting