CMS reforms prior authorization to improve care, streamline physician process

Editor's Note

The Centers for Medicare & Medicaid Services (CMS) has implemented a final rule reforming the prior authorization process, with the aim to reduce delays in patient care and boost electronic efficiency for physicians, the American Medical Association (AMA) News Wire reported January 23. The Department of Health and Human Services (HHS) estimates this reform "will save physician practices an estimated $15 billion over 10 years."

The new rule targets prior authorization in various government-regulated health plans, including Medicare Advantage, State Medicaid and CHIP programs, and Medicaid managed care plans, AMA reports. The reform will focus on technological and operational improvements and mandates that an electronic prior authorization process be integrated within the electronic health record to increase efficiency and automation.

Additionally, the new rule demands greater transparency in denial reasons, public reporting of program metrics, and accessibility of prior authorization information for patients. CMS is also requiring shortened processing times for prior authorization requests and that payers provide more information related to these requests. Enforcement of these policies includes possible CMS sanctions and civil monetary penalties.

Starting in 2026, payers must process urgent prior authorization requests within 72 hours and nonurgent requests within a week. To learn more, AMA points to FixPriorAuth.org.