CMS tightens drug prior‑auth
CMS proposed strict electronic deadlines for prescription drug prior authorisations and would require payers to publish approval and denial rates. Under the proposal urgent requests would need answers within 24 hours and standard requests within 72 hours, and insurers would have to disclose denial rates for drug prior authorisations. (healthcaredive.com) (techtarget.com) (haponline.org) (kffhealthnews.org)
The Centers for Medicare and Medicaid Services on April 10 proposed a federal clock for prescription drug prior authorization decisions, with faster deadlines and new public reporting. (cms.gov) Under the proposal, insurers in affected federal programs would have to answer urgent drug requests within 24 hours and standard requests within 72 hours. The rule would also require electronic prior authorization for drugs, rather than phone calls, faxes, and portal workarounds. (cms.gov) The proposal applies to Medicare Advantage organizations, Medicaid and Children’s Health Insurance Program fee-for-service programs, Medicaid managed care plans, Children’s Health Insurance Program managed care entities, and Qualified Health Plan issuers on the federally facilitated exchanges. CMS said the rule is docketed as CMS-0062-P. (cms.gov) Prior authorization is the insurer’s advance approval step before a patient can get some medicines covered. CMS said drug requests were left out of its January 17, 2024 final interoperability rule, which sped up prior authorization for many non-drug services but did not set the same framework for prescriptions. (cms.gov) This proposal extends that earlier framework to drugs and adds disclosure rules. CMS said affected payers would have to publish approval rates, denial rates, and appeals outcomes for drug prior authorizations, alongside expanded metrics for non-drug requests. (cms.gov) The agency is tying the rule to Health Level Seven Fast Healthcare Interoperability Resources standards, a common digital format for moving medical data between plans, doctors, and software systems. CMS said the goal is to let prescribers send requests and receive decisions inside electronic workflows instead of chasing paperwork across separate systems. (cms.gov; healthcarefinancenews.com) Hospital groups backed the direction of the rule. The American Hospital Association said April 10 that electronic standards for drug prior authorizations could reduce administrative burden and speed treatment, while payer-focused coverage said insurers are weighing the cost and operational work needed to meet the deadlines. (aha.org; techtarget.com) The proposal is not in force yet. It now goes through the federal rulemaking process, where CMS takes public comments before deciding whether to issue a final rule that would turn those clocks and reporting requirements into binding standards. (cms.gov)
