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.
Impacts on Practices and Patients
The need to obtain prior authorizations contributes to delays in treatment, staff burnout, and patient frustration, Mr. DeCabo said. On average, an otolaryngologist can devote 13 staff hours every week to processing roughly 41 prior authorization requests. In the 2022 American Medical Association survey, 90% of physicians said prior authorization requirements harm patient clinical outcomes (AMA. https://tinyurl.com/5v52dscr).
Prior authorizations are typically triggered for high-cost or device-intensive procedures. Inconsistencies among different insurance payers add another significant layer of complexity to administering prior authorizations. “What one insurer considers routine, another may flag for prior approval, forcing otolaryngology practices to navigate a maze of varying requirements, approval criteria, and documentation standards,” Mr. DeCabo said.
A lack of standardization means that physicians must maintain separate protocols for different payers, each with unique forms, timelines, and approval criteria. “What should be straightforward medical decision making is a complex administrative exercise,” Mr. DeCabo said.
Dr. Troublefield’s practice is inundated with prior authorization requests. Some require additional information about routine procedures, such as a tonsillectomy after a peritonsillar abscess. “Although the surgical indications are clear, some insurers insist that we obtain their permission before proceeding with an undeniably necessary surgery,” she said.
Another example is insurers’ need to authorize an image-guided CAT scan for patients who had prior endoscopic sinus surgery. “This should not require prior authorization because surgical indications are firmly established in otolaryngology literature,” Dr. Troublefield said.
Southcoast Physicians Group is unable to book surgeries in a timely manner when they require prior authorizations because it takes approximately 14 days for insurance companies to make these decisions. “When a patient requires a stat CAT scan, it can take up to five days for clearance,” she said. “Having a patient wait up to 19 days before we can obtain a biopsy to confirm our clinical suspicion can be potentially harmful to patients.”
Charleston ENT & Allergy currently submits prior authorization approval requests electronically through insurance payer portals when available, said Dr. Brown, which he believes is typical at other practices. Some practices have implemented AI bots that automatically navigate payer portals, submit prior authorization requests, and document responses in the system. When automation fails, dedicated teams handle phone-based communications with insurers.
“Current AI implementation costs are prohibitively expensive for many practices,” Dr. Brown said. “I fear that upcoming regulatory requirements will force practices to invest in costly technologies they can’t afford, creating financial strain while attempting to improve administrative efficiency.”
Preparations Underway
The AAO-HSN is taking a proactive approach to ensure members’ readiness for CMS’s new rule. Its website contains a comprehensive summary detailing the key provisions and deadlines otolaryngologists should know, Mr. DeCabo said (AAO-HNS. https://tinyurl.com/3edjez83). Additionally, its health policy team provides consultations and guidance for members as practices prepare for implementation.
Charleston ENT & Allergy is in the preliminary planning phase of implementing the new rule. The first step was to provide staff education and training, and then develop standardized processes to ensure full regulatory compliance and successful application programming interfaces (API) integration once technologies become available from payers. “We realize that our implementation schedule must align with payer readiness and system availability,” Dr. Brown said.
Charleston ENT & Allergy’s MIPS team is actively developing strategic approaches to efficiently capture and analyze data for the additional quality measure, building upon its existing data collection infrastructure.
Dr. Brown plans to educate patients on how to use new interoperability resources to optimize their healthcare outcomes. The practice’s patient-facing strategy focuses on:
- Providing clear guidance on accessing and navigating new digital tools;
- Enhancing patient understanding of prior authorization processes; and
- Developing educational materials that promote transparency in care decisions.
Implementation strategies are designed with the goal of having positive patient outcomes. “New processes must not only meet regulatory requirements, but also enhance care coordination, reduce administrative burden, and improve the overall patient experience,” Dr. Brown said.
The Role of EHR Vendors
Electronic health record (EHR) vendors play a critical role as intermediaries in healthcare data exchange, serving both healthcare providers and payers in a complex ecosystem, Dr. Brown said, and they will continue to do so with CMS’s new rule.
On the provider side, a practice’s EHR must seamlessly integrate with various APIs, requiring robust vendor support to implement new workflows and ensure smooth adoption within a practice. Simultaneously, payers depend on EHR vendors to establish secure, high-quality data connections that enable efficient information exchange.
The healthcare industry has long struggled with fragmented systems and poor interoperability among EHRs, insurance companies, and government agencies, Dr. Brown said. This systemic challenge stems from insufficient regulatory pressure and inconsistent standards enforcement by federal agencies.
Moving forward, successful healthcare data integration will require EHR vendors to prioritize true interoperability, not just basic connectivity, while federal regulators must establish and enforce more stringent requirements for seamless data exchanges across all healthcare stakeholders, Dr. Brown said.
Helping to Navigate Regulatory Changes
The AAO-HSN provides comprehensive support to help members understand complex regulatory changes, such as CMS’s new rule, and maximize their impact on practice operations, Mr. DeCabo said. They include:
- Education Resources: The Academy delivers timely updates through OTO News and The ENT Advocate and also maintains detailed resource libraries on its website with templates, checklists, and position statements.
- Direct Support: Its health policy team provides guidance on compliance questions, helps interpret new requirements, and assists with advocacy efforts.
- Peer Connection: Through ENT Connect, its online member forum, otolaryngologists share real-world implementation strategies, troubleshoot challenges, and learn from colleagues who’ve successfully navigated similar changes.
- Advocacy Tools: The Academy equips members with talking points, template letters, and advocacy toolkits to effectively engage their legislators and payers.
- Monitoring Services: The Academy tracks private payer policy changes, prior authorization updates, and submission requirement modifications, and then alerts members about critical developments that could impact their practices.
“This multi-layered approach ensures that no member faces these regulatory changes alone,” Mr. DeCabo said.
Advice on Adoption
For colleagues who are just beginning to prepare to adopt CMS’s new rule, Dr. Brown offers several tips.
- Study regulations thoroughly— Review the new rules in detail and read analytical articles that provide insights into implementation strategies and potential challenges.
- Leverage professional resources—Use educational materials and training programs that might be available through organizations such as AAO-HNS, Administrator Support Community for ENT, the American Medical Association, and the Medical Group Management Association to ensure comprehensive preparation for upcoming changes.
- Engage your operational team early— Work closely with staff to understand how these changes will affect existing workflows and develop adaptation strategies that minimize disruption.
- Map current processes—Document your current prior authorization workflows to identify specific areas that will need modification.
- Connect with insurance carriers— Reach out to carrier representatives to understand their specific rollout timelines, technical requirements, and interface specifications.
- Prepare your MIPS team—Ensure that your MIPS representatives are fully trained on new reporting criteria, with a particular emphasis on electronic prior authorization requirements and documentation standards.
How to Advocate for Improvements
A variety of ways to invoke change exist. The most impactful way is to become involved in the process, Dr. Troublefield said. Start by volunteering at your state’s otolaryngology organization, where many prior authorization issues are tackled. Massachusetts, for example, has devoted an entire subcommittee to this issue.
Additionally, you can participate on a national level by serving on committees. Recently, several otolaryngologists, including Dr. Troublefield, participated in a fly-in event in July with the Alliance of Specialty Medicine. Meetings were set up on their behalf with their respective senators and representatives in Washington, D.C., to discuss concerns about prior authorization, among other issues.
Otolaryngology was the most represented specialty at the event, with 11 dedicated members advocating, Mr. DeCabo said.
When looking to promote change, Dr. Brown recommends that otolaryngologists work through the AAOHSN and other medical associations to develop position statements, clinical guidelines, and advocacy campaigns to promote continued improvements in the prior authorization process.
The Academy has a robust advocacy infrastructure and has the strongest voice in otolaryngology. The AMA also represents the house of medicine in discussions about prior authorization for Medicare Advantage plans. “If you don’t want to march on Capitol Hill, you could support a political action campaign or cover for your partner who is more inclined to take action,” Dr. Brown said.
Physicians can systematically track prior authorization delays and denials, and their impact on patient care. Collect specific examples of delayed treatments, emergency interventions that could have been prevented, and patient outcomes affected by authorization delays. “This data can become powerful evidence for reform efforts,” Dr. Brown said. “Patient stories resound strongest with politicians, medical directors, and regulatory officials.”
Another option is to engage with state and federal legislators to support prior authorization reform bills. Many states have introduced legislation requiring faster turnaround times, limiting step therapy requirements for certain conditions, and mandating transparency in approval criteria. Otolaryngologists can provide clinical expertise to inform these efforts.
You could also participate in meetings with medical directors at insurance companies or serve on clinical advisory committees with insurance companies. “Work to establish evidence-based approval criteria specific to ENT procedures and develop streamlined processes for common, well-established treatments,” Dr. Brown said.
“These approaches work best when combined and sustained over time, because prior authorization reform typically requires persistent, multi-faceted advocacy efforts,” Dr. Brown said.
How Organizations Promote Advocacy
Prior authorization reform has been, and will continue to be, a prioritized advocacy directive of both the AMA and the AAO-HNS.
The AMA lobbied strongly for prior authorization reform, and these efforts contributed to the passage of CMS’s new rule. The AMA also strongly supports the Improving Seniors’ Timely Access to Care Act bill (https://tinyurl.com/ysc7wnh), bipartisan and bicameral federal legislation that would streamline prior authorization procedures in Medicare Advantage, Dr. Brown said.
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.
The Academy views the new rule as an important first step and will continue to push for comprehensive prior authorization reform to fully eliminate the administrative burdens and access barriers that still plague patient care, Mr. DeCabo concluded.
Karen Appold is an award-winning journalist based in Pennsylvania.
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