The Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Final Rule on January 17, 2024. The rule impacts the following government funded insurance programs and plans:

  • Medicare Advantage (MA) organizations,
  • Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs,
  • Medicaid managed care plans,
  • CHIP managed care entities, and
  • Issuers of Qualified Health Plans (QHPs) offered on the Federally-facilitated Exchanges (FFEs)

CMS’ rule is designed to improve the electronic exchange of health information and improve prior authorization processes for medical items and services, including a reduction of the burden on patients and providers.  It will result in clinicians being able to spend more time providing patient care and will help prevent avoidable delays in care for patients.

The rule is estimated to result in approximately $15 billion of savings over ten years.

Some specifics of the rule include:

  • Minimum time frame for expediting prior authorization decisions
  • Requirement that payers include a specific reason for denying a prior authorization request,
  • Requirement that payers publicly report prior authorization metrics,
  • Implementation of a more efficient electronic prior authorization process between providers and payers

Prior authorization relief at the state and national level has been an advocacy priority for the NC Medical Society and its members for many years.  Further analysis of the rule will determine if CMS’ rule measures up to the provisions being sought in legislation under consideration by Congress.

The prior authorization legislation pending at the NC General Assembly, HB649/Ensure Timely, Clinically Sound Utilization Review, passed the House during the 2023 session and is presently in Senate.  We look forward to working with the legislature to get this bill across the finish line in the upcoming 2024 session.

Appreciation is due to NCMS members and partner medical societies for their efforts to help ensure patients receive the necessary and appropriate medical care they deserve.  The new CMS rule is due in large part to the unified effort to fix a burdensome, costly and improper process.

The final CMS rule is available to review at: https://www.cms.gov/files/document/cms-0057-f.pdf.

A CMS fact sheet for rule is available at: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.