On January 17, 2023, the Centers for Medicare & Medicaid Services (CMS) held a roundtable with provider groups on improving the prior authorization process in governmental programs such as Medicare Advantage, Medicaid, and exchange plans under the Affordable Care Act.
Providers have long complained that health insurers’ prior authorization processes unnecessarily delay patient care and unfairly burden providers. For example, the American Medical Association has reported that 88% of physicians rate the burden of prior authorization as “high or extremely high.”
CMS has also previously recognized that the prior authorization process has been a major source of provider burnout and can create health risks for patients. To address these concerns, CMS has published proposed rules that would require Medicare Advantage plans to make determinations on prior authorization requests within 7 calendar days for routine requests and within 72 hours for urgent requests. In a call with reporters about the roundtable, CMS Administrator Chiquita Brooks-LaSure stated that CMS’s proposed actions “will significantly streamline the prior authorization process for clinicians, improve the health care experience for people we serve and ensure they can access the care they need.”