CMS Aims to Reduce Prior Authorization Burdens through Proposed Rule

December 15, 2022

On December 6, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would improve the ease and timeliness of prior authorization (PA) for patients covered by certain payers.  

Plans subject to the proposed rule include Medicare Advantage plans, Medicaid plans (both fee-for-service and managed care), and Children’s Health Insurance Program (CHIP) plans. Under the rule, these plans would be required to: 

• Implement standardized, electronic PA processes, 

• Disclose specific reasons for PA denials, 

• Report PA metrics to the public, and 

• Send PA decisions within three to seven days, depending on urgency. 

Additionally, the proposed rule would add a new “Electronic Prior Authorization” measure for Merit-based Incentive Payment System (MIPS) eligible physicians. CMS estimates that, together, these measures will save physician practices and hospitals more than $15 billion over the next decade.  

The MMA applauds this proposed rule and its potential for alleviating PA burdens faced by our members. We are eager to channel this momentum into advocating for additional laws, and/or the improved enforcement of existing laws, which may reduce PA burdens imposed by private plans in Minnesota.  

“Prior authorization continues to be one of the biggest hassles for patients and physicians,” said MMA President Will Nicholson, MD. “These changes are long overdue, but more needs to be done to reduce the overuse of prior authorization by insurers and pharmacy benefit managers.” 

The MMA plans to conduct further analysis of this proposed rule’s reach, limitations, and variance from existing Minnesota law on prior authorization. The MMA also plans to submit a public comment on the proposed rule by the deadline of March 13, 2023, and invites our members to submit comments as well.  

For further questions, please contact Adrian Uphoff, policy analyst.