Legislators urge CMS to finalize prior authorization reforms—and go further

A bipartisan group of legislators from both chambers of Congress is urging the Biden administration to finalize updates to prior authorization.

Nearly 300 members of Congress submitted letters to the Department of Health and Human Services backing rules proposed in December 2022 that aim to modernize prior auth. In these regulations, the Centers for Medicare & Medicaid Services (CMS) proposed requiring government payers to switch to electronic prior authorization by 2026.

If finalized, the changes would extend to Medicare Advantage, Medicaid managed care, Affordable Care Act exchange plans and state Medicaid agencies.

In the letter, senators said they "appreciate" that the regulations "attempt to strike a balance between program integrity and patient access to care."

"While we agree that [prior authorization], when used appropriately, is an important tool for payers to managed costs and ensure program integrity, we support CMS's efforts to protect beneficiaries, increase transparency around PA requirements and streamline this process for patients, providers and health plans," they wrote.

In addition, the senators urged CMS to build on the proposals in the rules by including a mechanism that would enable real-time decisions for routine approvals, which would shorten delays and reduce provider burden.

The letter also suggests that CMS shorten the window for a response to an expedited prior authorization request from 72 hours to 24 hours.

"We are concerned that delaying care for up to three days could jeopardize a patient's life, health or ability regain maximum function," the senators wrote.

The letter from representatives in the House echoes the same language and recommendations.

Provider organizations such as the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) also joined the chorus, calling for the regulations to be finalized.

“Our message to policymakers is simple: our patients cannot afford to wait or jump through unnecessary hoops to get care for painful, debilitating and life-threatening neurologic conditions. When finalized, these rules would remove barriers to patients’ timely access to care and allow physicians to spend more time treating patients and less time on paperwork,” said Russell R. Lonser, M.D., chair of the department of neurosurgery at Ohio State University and chair of the AANS/CNS Washington Committee, in a statement.