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

From Our Experts

You Got The Contract! ...Now What?! Part 3: Contract Implementation thumbnail You Got The Contract! ...Now What?! Part 3: Contract Implementation Contract Implementation: Turning Agreements Into Revenue  Securing a contract is worth celebrating—but what happens next is just as critical. Do you have a structured process for implementation, or does the contract sit in your inbox waiting for an issue to arise? A robust implementation workflow is essential to ensure accurate and timely reimbursement and avoid preventable denials. Deadline To Comment On CMS' Proposed Rule Is Today thumbnail Deadline To Comment On CMS' Proposed Rule Is Today VGM Group has submitted our comments on the CY26 CMS DMEPOS/Home Health Proposed Rule and encourages you to do the same (if you haven't done so already)!  Our comments provide key recommendations aimed at protecting patient access and supporting the HME community.  VGM's Key Recommendations Include: CONNECT for Health Act Gains Bipartisan Telehealth Support thumbnail CONNECT for Health Act Gains Bipartisan Telehealth Support On April 2, 2025, a bipartisan group of 60 senators reintroduced the CONNECT for Health Act, legislation that would expand patient access to telehealth services through Medicare while removing barriers to adoption. The bill would also make permanent the COVID-19 telehealth flexibilities currently set to expire Sept. 30. The lead sponsors of the bill are Sens. Brian Schatz (D-HI), Roger Wicker (R-MS), Mark Warner (D-VA), Cindy Hyde-Smith (R-MS), Peter Welch (D-VT), and John Barrasso (R-WY). [Vlog] Important Updates Regarding NIPPV NCD thumbnail [Vlog] Important Updates Regarding NIPPV NCD Watch below an important update from Ronda Burhmester, Sr. Director Payer Relations & Reimbursement, VGM & Associates, regarding non-invasive pressure ventilation. Make Your Voice Heard On The Competitive Bidding Program thumbnail Make Your Voice Heard On The Competitive Bidding Program “If the Competitive Bidding Program goes forward, it will be devastating—not just for providers like me but, most importantly, for the patients we serve,” said Jonathan Temple, owner of OxyMed LLC. You Got the Contract! Part 2: Maintaining It thumbnail You Got the Contract! Part 2: Maintaining It In our last article, we discussed the key provisions to be sure you know about your contract. It is critical to understand these provisions to help comply with the contract terms, fulfill your obligations as your business changes, and understand the payer's obligations and your rights under the contract. In this article we discuss some best practices for managing your contracts once you get them. Industry Uncertainty & Advocacy: What You Can Do Now thumbnail Industry Uncertainty & Advocacy: What You Can Do Now The proposed rule introduces broad structural changes without full clarity on implementation timelines or enforcement. Industry groups like VGM, AAHomecare, and CQRC are urging stakeholders to engage in advocacy to shape final rules. To prepare for the sweeping changes in the 2025 CMS Proposed Rule for DMEPOS, companies should take a multi-pronged strategic approach. Here is a breakdown of key preparation strategies: Alabama Durable Medical Equipment Association (ADMEA) Seeks New Executive Director thumbnail Alabama Durable Medical Equipment Association (ADMEA) Seeks New Executive Director The Alabama Durable Medical Equipment Association (ADMEA) is now accepting applications for the role of Executive Director. This is an exciting leadership opportunity for an individual with a passion for healthcare, industry advocacy, and association management.