Rule streamlining prior authorization is a step forward for primary care, 'but not a leap'

Key takeaways:

• CMS finalized a rule to streamline prior authorization requests and make the process more transparent.
• Experts said the changes are a positive step for PCPs, but will likely not alleviate burnout.

The new CMS rule aiming to streamline prior authorization signals a major step forward for primary care, but the process could still use some improvement, according to experts.

CMS finalized the Interoperability and Prior Authorization Final Rule in January, stating in a press release that the changes will modernize the United States health care system and streamline the prior authorization process. The changes will go into effect Jan. 1, 2026, and CMS has estimated that they will result in approximately $15 billion in savings over the next decade.

“We’re thrilled they finally finalized this rule,” Shari Erickson, MPH, chief advocacy officer and senior vice president of governmental affairs and public policy at the ACP, told Healio.

It has long been known that prior authorization in the U.S. needs improvements. David Broder, DO, an osteopathic physician specializing in internal medicine, said that, although the system works to ensure that all procedures are appropriate for patients, “it is generally considered the most burdensome regulatory issue facing physicians.”

“Overall, this new rule represents an improvement for patients and [primary care physicians],” Broder said. “Decreasing delays, providing specific feedback and increasing transparency are clear benefits that will improve patient care.”

Erickson said some physicians were “getting a little impatient” for the rule’s finalization, considering that it was first announced in December 2022 and “there's also interest on Capitol Hill in even doing more on this front.”

“I would say it is definitely a step in the right direction,” she said. “We were really pleased that they finalized it largely as they had proposed it, and so we're hoping that that is helpful for our [ACP] members in primary care. We're going to be asking them to share some stories with us about their experiences as this gets implemented so that we can really track any differences that they may be experiencing, but I do expect it will be better for them moving forward.”

The new rule makes a few major changes to the process: payers are now required to adjudicate requests much more quickly, they must provide a reason for a denial of care and they must report specific prior authorization metrics on their website.

“Last fall, I testified before Congress about how prior authorizations harm patients and physicians,” Steven P. Furr, MD, FAAFP, president of the American Academy of Family Physicians (AAFP), said in an interview. “From my experience, I know that some insurance plans made it so difficult to receive prior authorization for necessary tests, such as MRIs, nerve conduction studies, or cardiac stress tests, and that it can be easier to refer patients to a specialist and let them order the test.”

But that route “requires an unnecessary, more expensive office visit for the patient, which is antithetical to the purported ‘cost-saving’ purpose of prior authorization,” Furr said. Also, some specialists refuse to see patients until a test is ordered.

“Jumping through the hoops of this impossible system benefits neither the patients nor the physicians,” Furr said. “This decision will be a game changer for family physicians when it comes to averting care delays.”

Tighter timeline

The new rule states that prior authorization decisions must now be sent within 7 days for standard requests or 72 hours for urgent requests.

Furr said that “this is very different” from current practice, and that, “currently, there is not a unified timeline for prior authorization decisions within the health care system.”

“Medicare tries to answer prior authorization requests within 10 business days, while private insurance companies set their own parameters regarding how quickly prior authorization requests must be answered,” he said. “CMS requiring prior authorization decisions to be made within a set amount of time is a significant improvement. This is especially true for patients who urgently need medication or a procedure and cannot afford to wait for an extended period of time.”

Jeffrey Davis, DO, an osteopathic physician specializing in family medicine and an American Osteopathic Association board member, said he has also seen prior authorization delay diagnoses and increase patients’ anxiety, and hopes this change will reduce that in the future.

“I have had women with an abnormal mammogram and ultrasound wait weeks for approval of a breast MRI recommended by the radiologist who read her images,” he said. “The new rule does promise faster response times, so I hope to see things improve.”

Furr said CMS is targeting a critical issue in addressing the care delays that prior authorization can be responsible for, “and we expect these new requirements to improve workflows for PCPs and their staff by lessening delays in patient care.”

The standard timeline will also help with the fact that many practices have different Medicare Advantage plans they are working with, Erickson said.

“It's so variable and inconsistent in terms of the turnaround on some of these approvals,” she said. “So having the required time to be within 72 hours for the urgent requests or 7 days for standard requests will definitely be an improvement.”

Broder agreed, pointing out that the new rules cut the current turnaround times in half.

“This will not only decrease delays in patient care but will help reduce patient and family anxiety waiting for needed tests and procedures,” he said.

Similarly, Davis said he hopes the timeline change will improve things, but its success “will all depend on holding payers accountable to these times.”

He also noted that, “in many cases, the timing isn't always the worst problem; it is the decision.”

“Denials are often unfounded and restrict our patients' access to timely testing for diagnosis or therapeutic options for treatment,” Davis said. “In my experience, most denials do currently provide a reason for the denial. It just hasn't previously been required. However, many times, the treating physician's opinion differs from the insurance reviewer's opinion.”

Because the change only speeds up the process rather than simplifying it or eliminating it altogether, Broder said the rule change will be “a step in the right direction by reducing the wait for decisions but not a leap forward for providers.”

Transparency

Erickson said the changes that require payers to state a specific reason they have denied a request and report certain prior authorization metrics on their website will improve transparency.

“I think one of the biggest frustrations is that [PCPs] submit everything and then it comes back denied and they simply do not know why,” Erickson said. “That is where a lot of time is taken up in terms of calling and saying, ‘Okay, is there something missing from this?’”

Information that has been properly submitted can also get lost along the way, so providers are forced to go back and forth several times to ensure the payers have everything they need to make a decision, Erickson said.

“That is the biggest complaint I've heard,” she said. “It's nothing to do with the clinical relevance for that patient but much more about the administrative aspects of it and just the back and forth, the time that takes up that then obviously delays care for the patient.”

Furr said the AAFP is supportive of this new requirement and has been advocating CMS to implement the policy earlier than the scheduled 2026 date.

“With more transparency around decision-making for prior authorizations, we hope that the administrative burdens of fulfilling requests and appealing denials on both physicians and health plans will decrease over time,” he said.

Furr additionally said payers reporting certain metrics “will be valuable to patients and clinicians as they choose health coverage and the payers with which to contract.”

“We believe added transparency regarding the volume of prior authorization requirements and response time could drive process improvement and eventually reduce administrative burden and care delays,” he said.

Limitations

Although the experts all said the changes were a positive development, there are still some limitations. For example, Erickson said the ACP wishes that the time frame change went further — perhaps even to judgements being made “in real-time.”

“Our hope is that it would be closer to a real-time and preapproval, particularly for those services that a patient regularly receives, that are known to work well for that patient. Those should be able to be turned around much faster than this,” Erickson said. “Hopefully, we'll see this continue to move into a tighter time frame, but this is certainly an improvement from what we've seen so far.”

Furr said the AAFP agrees: the organization recommends that CMS “implement even shorter timelines for both nonurgent and urgent prior authorization requests — 48 hours and 24 hours, respectively.”

“We continue to believe that these time frames would lessen care delays and administrative burden while also improving patient experience,” he said. “The bottom line is that, in this electronic age, we will not be satisfied until there is real-time adjudication of any prior authorization requirements. Only then can we best serve our patients and give them the best health care possible.”

Additionally, Furr said the AAFP “would like to see CMS expand upon” the requirement mandating payers report certain metrics to include “more detailed data reporting on prior authorization requests, including requests that are ultimately handled through a ‘peer-to-peer’ consultation between the treating clinician and the plan’s medical director or other employed clinician.”

Davis said he believes “only physicians should be reviewing and making these decisions” — preferably those who are board certified and licensed to work in the state where the patient and physician reside.

“The best, highest quality health care is provided as part of the physician-patient relationship,” Davis said. “When other nonphysicians and nonpatients get involved in the process, outcomes can be affected. We should support well-trained and experienced physicians as the leader of the health care team.”

Broder also noted that the rule changes did not include medication authorization, which he said “would be consistent and extend the rule’s advantages,” and the fact that the rules do not apply to every insurance company.

“Could these rules be extended to apply to private insurance?” he said. “Physicians and other providers interface with many different payers. Different rules for each add to the complexity.”

With these limitations in mind, Broder and Davis said that the rule changes will likely not help address a major issue in the field: burnout.

“These changes will not resolve physician burnout,” Broder said. “Physicians will still be required to request prior authorization. Physicians will still be required to resolve any denials. And physicians will still need to address their patients’ questions and concerns regarding the process.”

Although organizations like the ACP and the AAFP can advocate for change, Furr said that, ultimately, “the next steps to alleviate many of the administrative burdens physicians face lie with Congress.”

“Policymakers must do their part to address the overwhelming volume of prior authorizations that physicians must complete,” he said. “Physician practices are being forced to hire dedicated staff to handle prior authorizations instead of investing in staff or tools that would enhance patient care. Instead of interfering in the decisions family physicians make in consultation with their patients, our health care system should improve access to the primary care patients need.”

Furr said he urges Congress “to swiftly pass the Improving Seniors Timely Access to Care Act” — legislation that would standardize and streamline prior authorization under the Medicare Advantage program, protecting patients from unnecessary care delays.

“This will ensure physicians can do what they do best: treating patients,” he said.

Reference:

• CMS finalizes rule to expand access to health information and improve the prior authorization process. https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process. Published Jan. 17, 2024. Accessed Feb. 16, 2024.