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The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would streamline processes related to prior authorizations (PA) for medical items and services. The proposed rule would also make information on plan PA performance – such as timeliness, as well as plan reasons for and methods of denials – public to providers and beneficiaries.
The proposed rule would apply to Medicare Advantage (MA) Plans, State Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid Managed Care Plans, CHIP Managed Care Plans, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs). CMS estimates that efficiencies introduced through these policies would save physician practices and hospitals, alone, over $15 billion over a 10-year period.
Key proposed provisions include:
These provisions would likely offer providers and beneficiaries helpful new information to understand plan PA processes and patterns of behavior.
We will release a more thorough summary in the coming days and work with membership to comment. The deadline to submit comments is March 13, 2023.