Today the Centers for Medicare & Medicaid Services (CMS) issued its rule requiring federal health plans—including Medicare Advantage plans, Medicaid plans, and Qualified Health Plans (QHP) on Federally Facilitated Exchanges (FFEs)— to establish an electronic prior authorization process that will be integrated into providers’ workflows.
The rule will require payers to streamline prior authorization processes with the electronic exchange of health care data. Beginning January 1, 2027, payers must provide a list of covered items and services (which will include procedures, images, and visits, but not prescription drugs at this time), identify documentation requirements for prior authorization approval, and support a prior authorization request and response between the physician and payer. Specific reasons for denied prior authorization decisions must be given, and urgent requests must be completed in 72 hours.
The use of prior authorization has increased significantly over the years. Providers report that the process, wherein a patient’s insurance plan requires pre-approval before medical care can be covered or reimbursed, can result in delayed cancer care and patient harm.
A statement from Everett E. Vokes, MD, FASCO, Board Chair of the Association for Clinical Oncology (ASCO) follows:
“This rule is an important step in ensuring that patient care takes priority over paperwork. Far too often necessary medical services are delayed due to excessive and burdensome prior authorization processes. Ensuring there is a single, easy-to-access electronic process in place to file forms and receive approvals within federal health plans is a welcome change. Timely access to care is critical for people with cancer and we’re hopeful this will help alleviate delays and lessen providers’ administrative burden.
“However, we are disappointed that the rule does not apply to drugs—which will continue to be an administrative burden to clinicians and their patients—and that many of these improvements won’t take effect until 2027. Urgent relief is needed now and the additional delay risks further harming patient access to cancer care.
“We look forward to weighing in with the cancer community’s perspective as CMS implements this rule. ASCO will also continue to work with the Administration, Congress, and state governments to advance policies that further reform prior authorization and improve the cancer care delivery system.”
Urge your lawmakers to take further action on prior authorization reform through the ACT Network.