CMS Releases Final Rule on Prior Authorization

On Jan. 17, 2024, the Centers for Medicare & Medicaid Services (CMS) released a final rule that makes important reforms in prior authorization (PA) programs for medical services and addresses both technological and operational requirements. Among the technology provisions is a requirement that impacted payers support an electronic PA process that is embedded within physicians’ electronic health records. This will bring much needed automation and efficiency to the current time-consuming, manual workflow. The final rule also requires that beginning in 2026, Medicare Advantage (MA) plans must convey PA determinations within 72 hours for expedited requests and seven days for standard requests. MA plans must also detail a specific reason for denying a PA appeal and report PA metrics as part of new transparency and reporting requirements. CMS notes enforcement of its policies, particularly around Medicare Advantage payers, can include CMS sanctions and civil monetary penalties. AANEM applauds CMS for finalizing these very important improvements to the PA system.

AANEM participates in advocacy efforts to call on Congress to codify these important policy changes by passing the Improving Seniors’ Timely Access to Care Act (Seniors’ Act) this year. CMS’ rule aligns with the Seniors’ legislation by tackling the overuse and abuse of PA by MA plans, which threatens access to patient care and increases provider administrative burden.