Health insurance providers that provide Obamacare plans, Medicaid, Medicare, and the Children’s Health Insurance Program are subject to the new regulation. Insurance companies must respond to urgent and non-urgent prior authorization requests within 72 hours and seven days.
This new standard request timeline reduces decision times by half for some payers. To aid in resubmitting the request or, if an appeal is necessary, the rule also mandates that all involved payers provide a clear explanation for any denied prior permission request. Last but not least, affected payers must publicly give previous authorization metrics, much as Medicare FFS does now.
Congress has recently focused on insurers’ demands for their approval before authorizing some physician-ordered treatments, which is a significant source of conflict with providers.
In addition to delaying patients’ access to care, doctors believe that prior permission compromises their ability to practice medicine. Insurance companies counter that it avoids low-value and needless medical services.
As regulators indicated their desire to curtail the practice, several sizable insurers have likewise reversed prior authorization rules in the last year.
“CMS is also finalizing API requirements to increase health data exchange and foster a more efficient health care system for all. CMS valued public input and considered the comments submitted by the public, including patients, providers, and payers, in finalizing the rule. Informed by these public comments, CMS is delaying the dates for compliance with the API policies from January 1, 2026, to January 1, 2027.”
“In addition to the Prior Authorization API, beginning January 2027, impacted payers will be required to expand their current Patient Access API to include information about prior authorizations and to implement a Provider Access API that providers can use to retrieve their patients’ claims, encounter, clinical, and prior authorization data. Also informed by public comments on previous payer-to-payer data exchange policies, we are requiring impacted payers to exchange, with a patient’s permission, most of those same data using a Payer-to-Payer FHIR API when a patient moves between payers or has multiple concurrent payers.”
“The rule also adds a new Electronic Prior Authorization measure for eligible clinicians under the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category and eligible hospitals and critical access hospitals (CAHs) in the Medicare Promoting Interoperability Program to report their use of payers’ Prior Authorization APIs to submit an electronic prior authorization request. Together, these policies will help to create a more efficient prior authorization process and support better access to health information and timely, high-quality care.”
Source CMS.gov
A bipartisan group of eight members mediated the measure on Wednesday, and they stated that Congress “must act to cement these gains,” alluding to the new CMS guidelines.
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