CMS’ New Rule Aims to Streamline the Prior Authorization Process

At the state level, the AMA has supported more than a dozen states in enacting laws in 2024 that reduce the care delays and wasted time experienced by patients and physicians due to prior authorization requirements.

The AMA launched a grassroots advocacy campaign on prior authorization reform housed on the website FixPriorAuth.org. Here, patient and physician stories are collected, and the website is used as a database for advocacy purposes.

The AMA also developed 21 principles that address prior authorization reform through an AMA-convened workgroup of 17 state and specialty medical societies, national provider associations, and patient representatives, and has worked with the insurance industry on implementation, Dr. Brown said (AMA. https://tinyurl.com/2s3hdu8p).

Similarly, the AAO-HNS has been actively advocating for prior authorization reform through multiple legislative initiatives and grassroots efforts (https://tinyurl.com/mrxr5v3n). It has highlighted the specific impact of prior authorization on otolaryngology practices. Like the AMA, it strongly supports the Improving Seniors’ Timely Access to Care Act bill.

The Academy also advocates for the Safe Step Act (https://tinyurl.com/evx2fv36), which would create an expedient and medically reasonable step therapy exceptions process whereby patients could receive timely and necessary care without experiencing unnecessary delays and burdensome administrative hurdles to treatment, Dr. Brown said.

The AAO-HNS continues to work collaboratively with other medical organizations and maintains active engagement with Congress to push for meaningful prior authorization reform that would reduce administrative burdens on physicians and improve patient access to timely care, Dr. Brown said.

Looking Ahead

Dr. Brown believes payers will respond positively to CMS’s new rule. “They are aware of the outcry from patients and providers, as the call for prior authorization reform has been steadfast,” he said. “Politicians have also been aligned in their support for Medicare Advantage reform.”

“The bottom line is that Congress has been increasingly active in investigating and proposing legislation to address Medicare Advantage practices, particularly focusing on inappropriate denials of care, use of artificial intelligence in coverage decisions, marketing abuses, and overpayments that benefit insurers rather than beneficiaries,” Dr. Brown said. “Hopefully, the combined weight of these pressures will contribute to payer compliance with the new rule and its directives.”

When implemented properly, Mr. DeCabo believes that CMS’s new rule will significantly benefit both otolaryngology practices and their patients, and that the changes will create momentum on issues related to prior authorization. “The Academy will continue monitoring payer compliance to ensure they follow both the letter and spirit of these rules, not just find workarounds,” he said.