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.

CMS' Proposed Rule Regarding Improvements to the Prior Authorization Process. Comment period open until Mar. 13

All fields marked with * are required.


TAGS

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

From Our Experts

The PHE Is Over: What's Next? thumbnail The PHE Is Over: What's Next? In today's episode of Industry Matters, Mandi Joyner, Senior Director of Marketing at VGM & Associates, talks with three of VGM's payer, billing, and reimbursement experts Ronda Buhrmester, Dan Fedor, and Craig Douglas about the end of the Public Health Emergency (PHE) and what that means for members. Adam Miller and Tom Powers Attend Policy Forum in Washington D.C. thumbnail Adam Miller and Tom Powers Attend Policy Forum in Washington D.C. On Wednesday, May 10, the AOPA Policy Forum held in Washington D.C. brought together over 100 stakeholders, manufacturers, and practitioners in the field of orthotics and prosthetics (O&P). John Gallagher and Greg Packer Attend Successful Fly-In on Capitol Hill thumbnail John Gallagher and Greg Packer Attend Successful Fly-In on Capitol Hill On May 10, John Gallagher, VP of VGM Government Relations, and Greg Packer, President of U.S. Rehab, participated in the AAHomecare Fly-In event in Washington D.C. The purpose of their attendance was to discuss key industry issues with members of Congress and their staff. FAHCS Secures Major Victory for HME Industry in Florida thumbnail FAHCS Secures Major Victory for HME Industry in Florida FAHCS secures a significant victory for the HME industry in Florida with a 7.5% rate increase to Medicaid Fee Schedule. Washington Governor Signs SB 5218 to Remove Sales Tax From CRT Equipment thumbnail Washington Governor Signs SB 5218 to Remove Sales Tax From CRT Equipment On May 4 in Olympia, Washington, Governor Jay Inslee signed SB 5218 into effect. This bill exempts complex rehab technology (CRT) equipment from sales tax, making it more accessible and affordable for those in need of it. CMS Proposes New Rules to Strengthen Transparency and Access to Quality Care in Medicaid and CHIP Programs thumbnail CMS Proposes New Rules to Strengthen Transparency and Access to Quality Care in Medicaid and CHIP Programs CMS has released a two new proposed rules that look to strengthen transparency as well as access to quality care within the Medicaid and CHIP programs. One of the proposed rules is titled Ensuring Access to Medicaid Services and the other is Managed Care Access, Finance, and Quality. S. 1294, A Bill to Provide a 75/25 Blended Rate for Non-Rural, Non-CBA Supplier Has Been Introduced thumbnail S. 1294, A Bill to Provide a 75/25 Blended Rate for Non-Rural, Non-CBA Supplier Has Been Introduced S. 1294, a bill to provide a 75/25 blended rate for non-rural, non-CBA suppliers has been introduced. Now we ask that everyone reach out to their senators asking for their support of this crucial bill. Read more about the bill and see an easy way to reach out to your senators. Washington State Passes Bill Exempting Sales Tax on Complex Rehab Technology: A Testimony to the Power of Advocacy and Collaboration thumbnail Washington State Passes Bill Exempting Sales Tax on Complex Rehab Technology: A Testimony to the Power of Advocacy and Collaboration Congratulations to Don Whitney of Inland Medical and the PAMES state association, along with the entire state of Washington, on the recent passing of SB 5218.