The move was welcomed by hospital and physician groups, as well as by members of Congress from both parties.
Prior authorization is a common tool used by insurers but is much maligned by doctors and patients, who say it’s often used to deny doctor-recommended care.
Under the final federal rule, health insurers participating in Medicare Advantage, Medicaid or the ObamaCare exchanges will need to respond to expedited prior authorization requests within 72 hours, and standard requests within seven calendar days.
The rule requires all affected payers to include a specific reason for denying a prior authorization request. They will also be required to publicly report prior authorization metrics.
The rule could impact millions of people and represents the Biden administration’s strongest efforts to force insurers to make changes to one of the most contentious practices in health care.
But the new rules don’t apply to veterans who receive their care through the Department of Veterans Affairs or the estimated 153 million Americans covered by private, employer-sponsored plans.
A bipartisan majority of lawmakers from both chambers of Congress have been calling on the White House to make changes to prior authorization. The leaders of the congressional push in a statement praised the rule.
“Today’s action by CMS is a major win for seniors and their families. These new regulations will make a big difference in helping seniors access the medical care they are entitled to without unnecessary delays and denials due to prior authorization,” Reps. Larry Bucshon (R-Ind.), Mike Kelly (R-Pa.), Suzan DelBene (D-Wash.), Ami Bera (D-Calif.) and Sens. Roger Marshall (R-Kan.), Sherrod Brown (D-Ohio), John Thune (R-S.D.) and Kyrsten Sinema (I-Ariz.) said in a joint statement.
Insurers have said prior authorization is a necessary way to control costs and cut down on unnecessary and expensive treatments.
But doctors and patients accuse insurers of using the process as an obstacle to necessary patient care, often forcing providers to navigate complex and widely varying paperwork requirements or face long waits for decisions.
