Proposed Medicare Rule Would Shorten Prior Auth Wait, Improve Transparency
By Phil West

In response to a proposed rule targeting prior authorization for medications across multiple federal programs, the Texas Medical Association lauded potential shortened time frames for drug request decisions and better data sharing for physicians and their patients, while pointing out that more could be done to relieve physicians of existing administrative burden.

If finalized, the rule could impact multiple Children’s Health Insurance Program (CHIP) and Medicaid programs and entities, plus other federal programs, before the end of 2027, including:

• Medicare Advantage organizations;
• State Medicaid fee-for-service programs;
• State CHIP fee-for-service programs;
• Medicaid managed care plans;
• CHIP managed care entities; and
• Certain Affordable Care Act (ACA) Marketplace health plans, including those from qualified health plan issuers.

In responding to the proposed rule, TMA told the Centers for Medicare & Medicaid Services (CMS) the plan would potentially reduce administrative burden for physicians by emphasizing timely decisions for prior authorization on medication.

Starting Oct. 1, 2027, the rule, if finalized, would allow no more than 24 hours for urgent requests or for certain Medicaid and CHIP requests, and 72 hours for standard requests for insurers issuing what CMS terms “qualified health plans” on the ACA Marketplace exchanges.

However, TMA has concerns regarding the time frames – which, while shortened, could still leave patients in limbo waiting for medications to be approved.

“The response times, while better than the 15 days previously allowed, are still too long,” TMA cautioned in its June 15 comment letter. “Patients who are suffering need immediate relief and should not have to wait 72 or 24 hours to have their medication approved by the payer.”

TMA President Bradford W. Holland, MD, told Texas Medicine Today prior authorization is “still one of the most time-consuming, frustrating, and patient care-delaying obstacles that physicians face on a daily basis, and it keeps us from giving patients the care and the drugs they need.”

He is especially encouraged to see Medicare Advantage among the CMS programs impacted by the proposed reforms.

“Medicare Advantage plans are much worse than traditional Medicare when it comes to putting up hurdles which impede the process of getting patients’ prescriptions approved and filled,” Dr. Holland said.

CMS’ proposed rule also updates interoperability standards for payers to streamline the prior authorization process. TMA says it would advance CMS toward “modernization efforts that move health care away from legacy workflows that heavily rely on faxes, phone calls, and payer-specific portals.”

CMS Administrator Mehmet Oz, MD, said via an online press release on the proposed rule that the goal is to standardize prior auth for medications and bring it up to speed with digital processes, because “patients should not have to wait days or weeks for approval to start the medication their doctor prescribed.”

In TMA’s praise for CMS, the comment letter invoked specific TMA policy (login required) supporting prior auth reform, a response to the administrative hurdles that prior authorization creates for physicians and their staff.

The most recent American Medical Association survey on prior auth found that its implementation continues to curtail patient access to care, exacerbate physician burnout, and delay necessary treatments sometimes resulting in hospitalization, disability, or even death.

TMA also applauded CMS’ provision improving patient access to prior auth information, noting, “Secure patient access to medical and prior authorization information helps patients take a more active role in their care.”

Similarly, TMA credited CMS for the proposed rule’s improvements to payer-to-payer data sharing, noting that patient data should follow patients whenever they change health plans, as that supports continuity of care and strengthens care coordination among physicians and other health care professionals.

Physicians seeking to resolve payment issues with Medicare, Medicaid, and commercial insurers can contact TMA’s Physician Payment Resource Center.