Prior‑auth rules shifting

Federal health officials are trying to make prior authorization faster on paper even as a Medicare pilot is slowing some care in practice. (cms.gov, statnews.com) On April 10, the Centers for Medicare & Medicaid Services proposed a rule that would extend electronic prior-authorization standards to drugs, shorten decision timelines across programs, and require more reporting on how approvals and denials work. The proposal also would add small-group marketplace plans sold through the federally facilitated Small Business Health Options Program to the list of payers covered by the interoperability rules. (cms.gov) The proposal builds on a 2024 final rule that already required many Medicare Advantage, Medicaid, Children’s Health Insurance Program, and federally facilitated exchange plans to answer urgent prior-authorization requests within 72 hours and standard requests within seven calendar days. The new proposal would bring many of those same electronic and transparency requirements to drug requests. (cms.gov, cms.gov) Prior authorization is the insurer’s advance yes-or-no before a scan, procedure, or prescription gets paid for. It sits between a doctor’s order and a scheduled appointment, which is why imaging groups say stalled approvals can push tests later and narrow the window for early diagnosis. (ama-assn.org, acr.org) At the same time, CMS is running a six-year Original Medicare test called the Wasteful and Inappropriate Service Reduction, or WISeR, model in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington from January 1, 2026 through December 31, 2031. CMS says the model uses artificial intelligence and machine learning with human clinical review for selected services that are vulnerable to fraud, waste, and abuse. (cms.gov, cms.gov) In Washington state, hospitals told Sen. Maria Cantwell that some Medicare patients are waiting two to four times longer for procedures now subject to WISeR review, according to a report described by STAT on April 22. Cantwell told Health and Human Services Secretary Robert F. Kennedy Jr. at a Senate Finance Committee hearing on April 22 that patients were waiting weeks for approvals on services that previously did not need them. (statnews.com) CMS says WISeR participant portals were supposed to be operating by January 5, 2026, with a 72-hour turnaround time for requests sent through those portals for dates of service on or after January 15. The agency also says requests sent through Medicare Administrative Contractors instead of those portals may take longer because another handoff is involved. (cms.gov) CMS says WISeR excludes inpatient-only services, emergency services, and services that would pose a substantial risk if substantially delayed, and says any recommendation for nonpayment must be made by licensed clinicians using standardized review procedures. The agency also says it will take corrective action if participants miss timeliness requirements. (cms.gov, cms.gov) Doctors have been warning for months that prior authorization already slows care. In the American Medical Association’s 2024 survey, 93% of physicians said prior authorization delays care, and 24% said it had led to a serious adverse event for a patient in their care. (ama-assn.org) The immediate question is whether CMS can standardize the paperwork without recreating the same delays inside new software portals and algorithmic review queues. The drug-rule proposal is still open for public comment, while WISeR is already live in six states and under pressure from hospitals and lawmakers to prove it can move faster than the system it was meant to fix. (cms.gov, cms.gov, statnews.com)