CMS on Jan. 17 finalized a rule to improve the prior authorization process.
The new rule will require some payers to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests, according to a news release. The rule, which goes into effect in 2026, will cut the decision timeframe in half for some payers.
Affected payers will also have to include specific reasons for denying a prior authorization and publicly report prior authorization metrics. They will have to implement a Health Level 7 Fast Healthcare Interoperability Resources prior authorization API to improve efficiency for electronic processing.
For many spine surgeons, prior authorizations impose a hurdle in patient care. In June last year, neurosurgeons were calling on the U.S. Department of Health and Human Services and CMS for improved prior authorization rules.
"What we need more than ever is fair prior authorization practices to be put in place," Brian Gantwerker, MD, of The Craniospinal Center of Los Angeles, said last year. "Insurers have increasingly outsourced their authorization duties in order to save themselves money and to absolve them of arbitrary medical decisions by local and state rules. This has become customary and obstructionist and benefits only their shareholders. If Congress and HHS are serious about saving money, they need to stop letting insurers dictate the rules of engagement and stop blaming physicians who are fighting on behalf of their patients."
CMS' new rule also updates API requirements to "increase health data exchange and foster a more efficient health care system for all," according to a news release. Affected payers will have until Jan. 1, 2027, to expand their API to include prior authorization information and implement a Provider Access API.