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

H.R. 5555 Gets Amended and Passes Energy and Commerce Committee thumbnail H.R. 5555 Gets Amended and Passes Energy and Commerce Committee On Wednesday, Dec. 6, The House Energy and Commerce Committee approved an amended version of H.R. 5555. The amended version of this bill extends the 75/25 blended rate in non-rural, non-CBAs through 2024 but does not include the 90/10 blended rate adjustment for suppliers in former CBAs. A Note from the SVP, Mike A Note from the SVP, Mike "Ike" Isaacson: November 2023 I hope this newsletter finds you healthy, happy, and focused on finishing out a great year! As many of you may have read, I have begun to focus more on our advocacy efforts and ensuring that VGM is here to support you in the legislative and regulatory aspects of your business. I know firsthand that some of you are dialed into the advocacy world, while others may not view these activities as an important part of your business. In our current government climate, I implore you to re-evaluate your a H.R. 5555 Gets Approved By Health Subcommittee thumbnail H.R. 5555 Gets Approved By Health Subcommittee On Wednesday, Nov. 15, the Health Subcommittee convened the health markup. The DMEPOS Relief Act of 2023 (H.R. 5555) was included in the discussion and approved. H.R. 5555 will now move on to the Energy and Commerce committee for consideration in the next few weeks. Important HME Legislation Being Discussed By Health Subcommittee on Wednesday thumbnail Important HME Legislation Being Discussed By Health Subcommittee on Wednesday On Wednesday, Nov. 15, the Health Subcommittee of the House Energy and Commerce Committee is set to meet and discuss important legislation. Included in this session will be H.R. 5555, DMEPOS Relief Act of 2023. This bill, led by Rep. Miller-Meeks (IA) and Rep. Tonko (NY) provides much-needed reimbursement relief. Read the full public memo here. Ronda Vlog: CGM News - Update On the 90 Days Billable on January 1, 2024 thumbnail Ronda Vlog: CGM News - Update On the 90 Days Billable on January 1, 2024 Be sure to listen to this important video update from Ronda Buhrmester on the upcoming change on how to bill a 90-day supply for CGMs. VGM's Ike Isaacson Gets 'Revved Up' thumbnail VGM's Ike Isaacson Gets 'Revved Up' WATERLOO, Iowa – A singular focus and a singular voice: That's what it takes to get the HME industry's message across to both lawmakers and regulators, says Mike “Ike” Isaacson, who was recently named senior vice president of government relations at VGM & Associates. A Summary of the Final Rule on the Lymphedema Treatment Act Recently Released by CMS thumbnail A Summary of the Final Rule on the Lymphedema Treatment Act Recently Released by CMS Craig Douglas, VP of Payer Relations, VGM and Associates, has reviewed the document and summarized the important information. Champions of Change Pushing for 55 in 55 Make Moves in Illinois thumbnail Champions of Change Pushing for 55 in 55 Make Moves in Illinois Champions of Change are making a strong start in the push for 55 in 55 (The goal of 55 in 55 is to schedule 55 visits with legislators and/or their staff in 55 days). Yesterday, a room of nearly 20 people gathered at VGM member, Prism Health Care Services in Schaumburg, IL to discuss S. 1294, current DME rates impacted by supply chain, delivery costs, employee costs, inflation, and so much more.