CMS Prior Authorization Proposal Aims to Streamline the Process and Improve Transparency

(By Kaye Pestaina, Justin Lo, Karen Pollitz, and Rayna Wallace for Kaiser Family Foundation Published: Feb 21, 2023)

The Center for Medicare and Medicaid Services (CMS) has issued a proposed rule designed to address the administrative hassles of prior authorization by requiring certain payers to implement an automated process, meet shorter time frames for decision making, and improve transparency. The proposal applies to payer processes mainly in public programs, with more limited application to health insurance marketplaces and no requirements on employer-sponsored coverage. The proposal launches the government’s next step in addressing a longstanding goal to improve health care administration through “interoperable” systems based on the use of standardized protocols for payers and providers across federal health programs. As CMS seeks input on this proposal (as well as five separate requests for information and a separate proposal on prior authorization standards and coverage criteria for Medicare Advantage plans), we can expect that prior authorization and improved data sharing in health care will be front and center in upcoming policy discussions. Continue reading here…

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