Prior Authorization

New prior authorization reforms show power of physician advocacy

Andis Robeznieks , Senior News Writer

AMA News Wire

New prior authorization reforms show power of physician advocacy

Mar 14, 2024

Just before they headed to Capitol Hill to meet with lawmakers, the physician advocates and medical society staffers gathered for the AMA National Advocacy Conference in Washington received a vivid reminder that their advocacy efforts make a difference as one of the conference’s first government speakers discussed new federal rules on prior authorization.

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“I, as well as our CMS team, heard directly from your members about how burdensome processes were interfering with patient care and were also contributing to clinician burnout,” Chiquita Brooks-LaSure, administrator for the Centers for Medicare & Medicaid Services (CMS), said at the conference, which was held last month. 

Chiquita Brooks-LaSure
Chiquita Brooks-LaSure

“Our policies are informed by your voices, and it’s our hope that our final rules reduce patient delays and streamline the process for physicians, so that you are better able to get people the care they need,” Brooks-LaSure added.

She was introduced by AMA Immediate Past President Jack Resneck Jr., MD, who let her know the CMS actions will make a difference.

“I really just cannot thank you enough for listening to patients and to physicians and bringing forward a pair of prior authorization reforms that are so deeply needed,” Dr. Resneck said, referring to the two regulations the agency finalized, each of which contained numerous reforms. “They're going to reduce the administrative burdens that we all experience as practicing physicians every day—burdens that really do contribute to evidence-based care for our patients being delayed and denied.”

Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Learn how the AMA is tackling prior authorization with research, practice resources and reform resources.

AMA President Jesse M. Ehrenfeld, MD, MPH, said the new rules will "go a long way to reducing the burdens on physicians, and most importantly, reducing delays in care for our patients." Dr. Ehrenfeld discussed the reforms and their impact in a recent episode of “AMA Update.”

The new CMS final rule, which takes effect in 2026 and 2027, is part of the agency’s comprehensive plan to improve prior authorization. Among other advancements, this latest effort electronically streamlines the prior authorization process for physicians providing medical services under:

  • Medicare Advantage plans.
  • State Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs.
  • Medicaid managed care plans and CHIP managed care entities.
  • Qualified health plans on federally facilitated exchanges.

Beginning in 2026, insurers will be required to share specific explanations of why prior authorization requests are denied. Metrics on how often insurers approve or deny prior authorization requests will also be made public, creating more transparency and accountability.

Starting in 2027, plans will be required to support an electronic prior authorization process that is embedded within a physician's EHR. That change will bring automation and efficiency to what is currently a manual, and oftentimes time-consuming process. These changes will save physician practices an estimated $15 billion over 10 years, according to the U.S. Department of Health and Human Services.

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“We as an agency will continue to keep looking at what we need to do on prior authorization,” Brooks-LaSure said.

“We're obviously going to see what's happening with how our rules are helping but have heard loud and clear that drugs are an area that people would like us to pay attention,” she added. “And while we're having all of this change in the Medicare drug benefit, it's a good time to look at if the procedures that we have in place really work to make sure that, ultimately, people are getting the care that they need.”

Medicare, Medicaid, CHIP and the insurance marketplace provide health insurance coverage for 160 million Americans, Brooks-LaSure said, noting that the marketplace enrolled a record 21 million people for the 2024 plan year.

“Our mission is to get all of those eligible for coverage enrolled and to make sure that coverage is not just an insurance card in their pockets, but that it means that they have access to the care that they need,” Brooks-LaSure said, adding that physicians play a vital role in ensuring access and advancing health equity.

“You are often the critical messengers in helping people get the care they need, to get enrolled in health coverage, to understand their coverage, obtain the necessary preventive care, and get access to necessary services to address socioeconomic needs,” she said. “Without you, the dream of health equity could never become a reality.”

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