CMS finalizes rule to streamline Medicare prior authorizations
The Centers for Medicare & Medicaid Services (CMS) has finalized a rule to reduce administrative burdens from prior authorization requirements in Medicare Advantage plans. The policy aims to speed up approvals and improve patient access to care. It will affect millions of enrollees starting in 2026.
On September 20, 2024, CMS announced the finalization of a rule designed to overhaul the prior authorization process for Medicare Advantage organizations. This comes amid growing concerns over delays in care due to administrative hurdles. The rule builds on a proposed version from late 2023, incorporating stakeholder feedback to balance efficiency and oversight.
Prior authorizations, which require insurers to approve certain treatments or services before they are provided, have seen a 20% increase in usage over recent years, according to CMS data. This has led to delays for patients, particularly those with chronic conditions. The new rule mandates that Medicare Advantage plans make decisions on expedited prior authorization requests within 72 hours and standard requests within seven days.
"This rule will reduce administrative burdens on providers while ensuring timely access to clinically necessary care for Medicare beneficiaries," said CMS Administrator Chiquita Brooks-LaSure in a statement. The policy also requires plans to establish a utilization management committee with at least three clinicians to review requests, aiming to incorporate medical expertise into denials and approvals.
The changes apply to the more than 30 million people enrolled in Medicare Advantage plans as of 2024. Implementation is set for January 1, 2026, giving plans time to adjust systems. CMS emphasized that the rule aligns with broader efforts under the Biden administration to lower healthcare costs and improve equity.
Background context includes the Consolidated Appropriations Act of 2021, which directed CMS to address prior authorization issues. While the rule focuses on Medicare, advocates hope it influences commercial insurance practices. No major contradictions were noted in the announcement, though some industry groups have expressed concerns about potential increases in plan costs.