Medicare Advantage plans must respond to urgent prior authorization requests for drugs within 24 hours and standard requests within 72 hours. proposed rules From the Centers for Medicare & Medicaid Services (CMS).
Released Friday, the proposed rule would also require full disclosure of the results of denials and appeals of claims. CMS press release. Although CMS issued a final rule With the prior authorization deadline for medical tests and procedures set for February 2024 under the Biden administration, the drugs were not included.
“Last year, we got 80% of the insurance industry to agree to eliminate prior authorization for routine medical services like diagnostic imaging, physical therapy and outpatient surgery,” HHS Secretary Robert F. Kennedy Jr. said in the press release. “This rule builds on that agreement by making it easier for patients to get the medicines they need by reducing delays and enabling real-time decisions.”
CMS Administrator Mehmet Oz, MD, MBA, said that “Patients should not have to wait days or weeks for approval to start a medication prescribed by their doctor.”
He said, “This proposal moves prior authorization into the digital age, replacing fax machines and fragmented systems with real-time electronic workflows.” “We’re … making sure providers can focus on caring for patients instead of obsessing over red tape.”
CMS proposed that compliance dates would generally begin in 2027.
In addition to Medicare Advantage, the electronic prior authorization requirements outlined in the rule will also apply to health plans on Medicaid, the Children’s Health Insurance Program (CHIP), and the federally facilitated Affordable Care Act health insurance exchanges. CMS said payers must report on approval and denial rates for drug-related prior authorizations, as well as decision timelines and appeal outcomes.
The agency is also proposing that payers support electronic prior authorization for drugs covered under pharmacy benefits such as Part D — which includes three separate standards for querying formulation information and determining real-time coverage information, according to a fact sheet On the proposed rule.
In addition, plans must report on the use of prior authorization-related application programming interfaces – applications that outside developers can use to make it easier to interact with plans electronically. “These measures will give patients, providers, and policymakers a clearer understanding of how prior authorization requests are handled consistently and efficiently,” the press release said. “Public reporting would increase accountability and make it easier to compare how plans handle prior authorization decisions.”
Finally, CMS also issued requests for information on a number of topics, including strengthening healthcare cybersecurity and system resiliency; streamlining “step therapy” processes; and improving prior authorization for laboratory tests, durable medical equipment, prosthetics, orthotics, and supplies.
At an event focused on accountable care organizations in Washington on Monday, Oz touted his agency’s progress on easing prior authorization requirements. To this he said, “I want to shut down the industry because they are taking some steps forward.” “We’re not doing this; they’re doing that. It’s a problem everyone agrees.”
However, he added, “The provider side of the equation is not fully engaged with payers, and for that reason it’s hard to engage providers. How do you get them to realize that not spending 12 hours a week of staff time — paying them (let’s say) $30 an hour — to fight the insurance company is really good? Nobody’s happy. If we can figure out a way to do that with reasonable (computer) standards, it’s going to change your life, your practice. Will make it even better. Successful.”
