CMS finalized a rule Jan. 17 requiring certain payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send decisions within 72 hours for urgent requests and seven calendar days for standard requests beginning in 2026.
This move was made in an attempt to make the prior authorization process more efficient and is estimated to save $15 billion over the next decade. The update was met with generally favorable reactions from various payers and provider groups.
"Patients need protection from arbitrary critical care denials and delays due to insurance company prior authorization abuse. It is important that CMS is taking a vital step to ensuring this protection by setting guide rails for prior authorization that should rein-in the worst abuses," Federation of American Hospitals President and CEO Chip Kahn told Becker's after the rule was finalized.
Meanwhile, state legislatures are continuing to address prior authorization at a more local level, with 28 states introducing more than 70 prior authorization bills during their current legislative sessions, according to American Medical Association President Jesse Ehrenfeld, MD.
Other changes physicians want to see with prior authorization include the integration of artificial intelligence into the process, with 48% of physicians in an AMA survey saying that AI would be most helpful in the "automation of insurance prior authorization."