From the finalization of a rule CMS estimates will save $15 billion over 10 years to the implementation of another, here are four prior authorization updates Becker’s has reported on since Dec. 29:
1. CMS finalized a rule to streamline the prior authorization process and improve the electronic exchange of health information that it estimates will save $15 billion over 10 years. Beginning primarily in 2026, certain payers will be required 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.
The move was met favorably by payer and provider groups. A group of lawmakers that has pushed for prior authorization reforms applauded the rule, which CMS finalized Jan. 17, but said Congress must now “cement these gains into law.”
2. Hospital and payer groups were broadly supportive of proposed changes to Medicare Advantage prior authorization and broker compensation regulations. CMS published its proposed Medicare Advantage rules for 2025 on Nov. 6. The agency pitched limiting plans’ payments to brokers and prohibiting plans from paying value-based bonuses to third-party marketing organizations.
3. A CMS rule aiming to streamline Medicare Advantage and Part D prior authorizations took effect Jan. 1. CMS issued the final rule in April 2023, requiring that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.
4. Rep. Michael Burgess, MD, explained why he is pursuing gold-card legislation that would exempt qualifying providers from prior authorization requirements for Medicare Advantage plans.