VGM & ASSOCIATESHealthcare MSO
Full Menu Search

CMS Proposed Rule Regarding Improvements to the Prior Authorization Process

Published in Government Relations on December 27, 2022

CMS has issued a proposed rule aimed at streamlining the Prior Authorization (PA) process for medical products and services. Any changes that come about due to this effort would impact Medicare Advantage (MA) plans, Medicaid, and CHIP plans (including MCOs) with implementation in 2026. 

The proposed rule suggests many changes to help streamline the PA process, such as: 

  • Requiring payers to be specific with providers about the reason for a denial 
  • Requiring payers to annually report certain prior authorization metrics publicly 
  • Requiring payers to send prior auth decisions to providers within: 
  • 72 hours for urgent requests (also considering 48 hours) 
  • 7 calendar days for standard requests (also considering 5 days).  
  • Requiring payers to exchange patient data when a patient moves between payers or has multiple payers (patient opt-in required) 

The full proposed rule (403 pages) and instructions for submitting comments (pg. 2) can be found here. A condensed fact sheet regarding the proposed rule can be found here.  

The DMEPOS provider community, along with many other provider types, would welcome many of these changes, and it is estimated that the changes being considered would save providers throughout the healthcare continuum an estimated $15B over the initial 10-year period after implementation. VGM will be submitting comments regarding the proposed rule, and we encourage you to submit your own comments, either directly to CMS or send your comments to us so that we can incorporate those comments into ours.  

The deadline to submit comments is March 13, 2023. There may be other considerations to either enhance the objectives already listed in the proposed rule or others that should be added to the list. Please take the time to review the proposed rule and submit your comments. If you choose to send your comments to VGM please fill out the form below.

All fields marked with * are required.

TAGS

  1. billing & reimbursement
  2. reimbursement
  3. vgm
  4. vgm government

Get Connected

Stay up-to-date on the latest resources and news provided by VGM & Associates.

Sign Up for Email

From Our Experts

OIG Report Signals Increased Fraud Oversight for DMEPOS Suppliers thumbnail OIG Report Signals Increased Fraud Oversight for DMEPOS Suppliers The HHS Office of Inspector General (OIG) recently released a white paper examining ongoing Medicare fraud involving durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Preparing for Increased Audit Activity: How VGM Group and The van Halem Group Can Help thumbnail Preparing for Increased Audit Activity: How VGM Group and The van Halem Group Can Help The recent HHS Office of Inspector General (OIG) report on DMEPOS fraud signals that CMS is likely to increase oversight activities across the industry. The report calls for enhanced supplier enrollment screening, more aggressive medical reviews, expanded use of artificial intelligence and data analytics, greater physician order verification, and increased scrutiny of supplier ownership and billing practices. CMS Releases Critical Updates On The Medicare Supplier Enrollment Moratorium And Round 2028 Competitive Bidding Program thumbnail CMS Releases Critical Updates On The Medicare Supplier Enrollment Moratorium And Round 2028 Competitive Bidding Program See CMS' notice on the Medicare Supplier Enrollment Moratorium below: Medicare's DMEPOS Supplier Enrollment Moratorium Has Expired | Action Required for Round 2028 Bidders This message is to inform you that the 6-month temporary moratorium on accepting Medicare supplier enrollment applications, which became effective on February 27, 2026, has now expired as of August 27, 2026. CMS Updates CBIC Website Bid Preparation Guidance for Round 2028 Competitive Bidding Program thumbnail CMS Updates CBIC Website Bid Preparation Guidance for Round 2028 Competitive Bidding Program On August 13, 2026, CMS posted several updated and new Fact Sheets and one new FAQ to the Bid Preparation Phase page on the CBIC website. Providers interested in submitting a bid for Round 2028 can find more program details, including the estimated number of contract awards, for each category. Important: HME Supplier Survey on Round 2028 Competitive Bidding Impact thumbnail Important: HME Supplier Survey on Round 2028 Competitive Bidding Impact AAHomecare is conducting a brief survey to help quantify the potential impact that Medicare's Remote Item Delivery (RID) model of Competitive Bidding would have on HME suppliers providing continuous glucose monitors (CGMs), insulin pumps, ostomy supplies, and/or urological supplies. Survey findings will be used to inform discussions with the White House, the Centers for Medicare and Medicaid Services (CMS), and Congress about the potential effects on supplier businesses, jobs, and patient... CMS Makes Finalized Change to DMEPOS Competitive Bidding Program thumbnail CMS Makes Finalized Change to DMEPOS Competitive Bidding Program The Centers for Medicare and Medicaid Services (CMS) has issued the FY 2027 Inpatient Rehabilitation Facilities (IRF) Prospective Payment System (PPS) Final Rule (CMS-1845-F), increasing the DMEPOS Competitive Bidding Program's bid surety bond amount to $100,000 (previously $50,000).... VGM Government Relations Launches State Payer Resource Hub for DMEPOS Providers thumbnail VGM Government Relations Launches State Payer Resource Hub for DMEPOS Providers This resource brings together key information frequently used by DMEPOS providers. Kentucky Governor Announces Reprieve from Previously Announced Kentucky Medicaid 4% Rate Cut thumbnail Kentucky Governor Announces Reprieve from Previously Announced Kentucky Medicaid 4% Rate Cut The administration expects the surplus funding to sustain current reimbursement levels through June 2027.

Give your business an advantage over the competition.

Become a Member