The chronically slow and muddled process of gaining prior authorization for medical devices and services will be simplified for patients with public insurance, if a proposal by the Centers for Medicare and Medicaid Services is adopted.
The changes, which would take effect in 2026, are centered on expediting decisions and sharing information more efficiently. Among the aims proposed are:
- Faster response times. Payers would be required to provide prompt and specific reasons for denying a prior authorization. This helps patients get care faster, or in the case of a denial, moves the appeals process forward sooner.
- Interoperable software systems. A new interface would allow payers, providers and patients across federal health programs access to requests and denials in an automated system. This increases the availability of data to all parties.
- Publicly available data. In a nod to transparency, payers would be required to list all services requiring prior authorization and specific metrics about approvals, denials, appeals and timeframes on their website.
The requirements would affect nearly all public payers including Medicare, Medicaid and Children’s Health Insurance Program plans, as well as qualified health plans offered via the federal insurance marketplace.
The proposal includes items and services, but not prescription drugs. Diagnostic tests and imaging services necessary to confirm a diagnosis or rule out others, for example, would be included. So would durable medical equipment, such as home oxygen systems. The changes would be an improvement to the current system and could be a springboard for folding in medications in the future.
Reducing the Burden
Prior authorization was originally designed to reduce waste, but it has turned into a menacing process for everyone involved. Nealy all physicians report that it delays care, and 80% cite that prior authorization can at least sometimes lead to treatment abandonment, which is detrimental to patients.
It is also time intensive. Physicians and their staff spend, on average, 14 hours per week processing requests and appeals. It’s no wonder 88% of physicians report the burden associated with prior authorization to be “high” or “extremely high.”
If federal officials move forward and adopt the proposal, it would be a huge step forward in the advocacy community’s long campaign to limit the harms of overused prior authorization.