CMS’ New Rule Aims to Streamline the Prior Authorization Process

The Centers for Medicare and Medicaid Services’ Interoperability and Prior Authorization Final Rule (https://tinyurl.com/sy2sbhv6), which aims to improve the prior authorization process through policies and technology, takes effect January 1, 2026.

The new rule, which was released in January 2024, is expected to benefit providers and patients while bringing new requirements for payers. Payers will need to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., nonurgent) requests. Payers will have to provide a specific reason for a denied prior authorization decision.

“The new rule provides much-needed change for otolaryngologists and their patients,” said Gene Brown, MD, otolaryngologist, president, and CEO of Charleston ENT & Allergy in Charleston, S.C. “For physicians, the prior authorization process will be streamlined, electronic, and much more transparent because reasons for denials will be required. For patients, wait times for prior authorization will be reduced.”

The regulation falls short in several critical areas, however, Dr. Brown said. Most notably, the rule’s timeframe requirements, while improved, remain inadequate. Healthcare advocates pushed for 24-hour decisions for expedited prior authorizations and 72-hour turnarounds for routine requests.

Additionally, the rule doesn’t affect the prior authorization processes for Medicare Part B or Part D drugs (e.g., prescription drugs that may be self-administered, administered by a provider, or dispensed or administered in a pharmacy or hospital). “This carve-out is significant because Part B drugs are often subjected to stringent prior authorization and step therapy protocols,” said Harry DeCabo, director of advocacy for the American Academy of Otolaryngology–Head and Neck Surgery in Alexandria, Va.

Yolanda Troublefield, MD, JD, an attending otolaryngologist at Southcoast Physicians Group in Dartmouth, Mass., and a clinical instructor of surgery at Brown School of Medicine in Providence, R.I., also has concerns about CMS’s new rule.

“On the one hand, insurers are asking us to maximize medical management and treatment of diseases prior to surgical intervention, and on the other hand, no structures are in place in order to get Part B medications approved in a timely fashion,” she said.

Starting in 2027, CMS’s new rule will place new requirements on providers who participate in the Medicare Merit-Based Incentive Payment System (MIPS). The rule creates a new measure, titled “electronic prior authorization,” regarding the Health Information Exchange objective for the MIPS Promoting Interoperability performance category and the Medicare Promoting Interoperability Program. “This will place more administrative burdens on physicians without meaningfully improving patient care or access,” Mr. DeCabo said.