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Regulatory


LEGISLATORS URGE CMS TO FINALIZE PRIOR AUTHORIZATION REFORMS—AND GO FURTHER

By Paige MinemyerJun 22, 2023 03:50pm
CongressCenters for Medicare & Medicaid ServicesPrior AuthorizationMedicare
Advantage
Provider organizations such as the American Association of Neurological Surgeons
and the Congress of Neurological Surgeons also joined the chorus, calling for
the regulations to be finalized. (Getty/BrianAJackson)

A bipartisan group of legislators from both chambers of Congress is urging the
Biden administration to finalize updates to prior authorization.




Nearly 300 members of Congress submitted letters to the Department of Health and
Human Services backing rules proposed in December 2022 that aim to modernize
prior auth. In these regulations, the Centers for Medicare & Medicaid Services
(CMS) proposed requiring government payers to switch to electronic prior
authorization by 2026.




If finalized, the changes would extend to Medicare Advantage, Medicaid managed
care, Affordable Care Act exchange plans and state Medicaid agencies.

In the letter, senators said they "appreciate" that the regulations "attempt to
strike a balance between program integrity and patient access to care."


RELATED

Providers press CMS to finalize prior authorization reforms to alleviate major
administrative burdens

"While we agree that [prior authorization], when used appropriately, is an
important tool for payers to managed costs and ensure program integrity, we
support CMS's efforts to protect beneficiaries, increase transparency around PA
requirements and streamline this process for patients, providers and health
plans," they wrote.



In addition, the senators urged CMS to build on the proposals in the rules by
including a mechanism that would enable real-time decisions for routine
approvals, which would shorten delays and reduce provider burden.

The letter also suggests that CMS shorten the window for a response to an
expedited prior authorization request from 72 hours to 24 hours.

"We are concerned that delaying care for up to three days could jeopardize a
patient's life, health or ability regain maximum function," the senators wrote.

The letter from representatives in the House echoes the same language and
recommendations.



Provider organizations such as the American Association of Neurological Surgeons
(AANS) and the Congress of Neurological Surgeons (CNS) also joined the chorus,
calling for the regulations to be finalized.

“Our message to policymakers is simple: our patients cannot afford to wait or
jump through unnecessary hoops to get care for painful, debilitating and
life-threatening neurologic conditions. When finalized, these rules would remove
barriers to patients’ timely access to care and allow physicians to spend more
time treating patients and less time on paperwork,” said Russell R. Lonser,
M.D., chair of the department of neurosurgery at Ohio State University and chair
of the AANS/CNS Washington Committee, in a statement.

PayersProvidersRegulatoryMedicaid Managed Care

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