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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.

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