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- CAP Applauds CMS Prior Authorization Rule Prioritizing Patients’ Access to Care
On January 18, the Centers for Medicare & Medicaid Services (CMS) released a final rule that makes important reforms in prior authorization programs for medical services. The rule is a direct result of important advocacy efforts taken by the CAP together with the American Medical Association and other physician organizations to addresses prior authorization in government-regulated health plans.
On March 13, 2023, the CAP wrote a letter to the CMS asking them to streamline the prior authorization process, reduce physician practice burdens, and prevent patient care delays in Medicare Advantage and other public health plans. The CAP emphasized how streamlining or automating prior authorization and other utilization management processes is critically important, and that it is imperative that any cost-control measures balance other considerations and continue to ensure access to timely and appropriate care.
In the final rule, the CMS has taken important steps toward improving the prior authorization process implementing many of the CAP’s requests. Improvements include:
- Electronic prior authorization process that is embedded within physicians’ electronic health records—bringing automation and efficiency to manual workflow.
- Mandating shortened prior authorization processing timeframes.
- Enhancing transparency around prior authorization, including requirements for specific denial reasons and public reporting of program metrics.
- Requiring that payers provide physicians and patients more prior authorization-related information.
The CMS noted enforcement of its policies, particularly around Medicare Advantage payers, can include CMS sanctions and civil monetary penalties. These policies will go into effect January 1, 2027. Download the prior authorization final rule fact sheet.