CMS has finalized prior authorization and electronic health information policy updates that are expected to create approximately $15 billion in savings over the next 10 years.
The CMS Interoperability and Prior Authorization Final Rule makes four key changes to the prior authorization process for Medicare Advantage and managed Medicaid/CHIP plans, according to a Jan. 17 CMS news release:
• Payers must implement a standardized prior authorization programming interface to make payer-provider prior authorization processes more efficient from end to end.
• Payers must provide specific reasonings for denying prior authorization requests to make resubmissions or appeals more efficient.
• Affected payers are required to send prior authorization decisions within 72 hours by 2026.
• Payers under CMS jurisdiction must publicly report prior authorization metrics.
Also, beginning in January 2027, affected payers will be required to expand their current patient and provider access capabilities to give patients and providers access to more information about prior authorizations, according to the release.
These updates are expected to ease administrative burdens on healthcare providers and ensure patients can access care more efficiently and quickly, the release said.
The Medical Group Management Association applauded the policy changes made by CMS, according to a Jan. 16 news release from the organization.
"The increased transparency provisions … will help shine a light on the egregious abuse of prior authorization by payers under the guise of looking out for patients' best interests," Anders Gilberg, the MGMA's senior vice president of government affairs, said in the release. "This final rule is an important step forward towards MGMA's goal of reducing the overall volume of prior authorization requests.”