Timesaving. Cost-saving. Life-changing.
Those are three of the countless ways to describe the impact of the rule on prior authorization that was finalized by the Centers for Medicare & Medicaid Services (CMS) on Jan. 17. The rule brings about much needed transparency and efficiency to a broken process.
"The reforms … are a significant, significant step in the right direction," said AMA President Jesse M. Ehrenfeld, MD, MPH. "They're going to go a long way to reducing the burdens on physicians, and most importantly, reducing delays in care for our patients."
Dr. Ehrenfeld discussed the reforms and their impact in a recent episode of “AMA Update.”
Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians.
Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.
Three significant changes
An important note about the final rule on prior authorization is that it only applies to government-regulated health plans. Those plans include:
- Medicare Advantage.
- Medicaid.
- Children's Health Insurance Program.
- Fee-for-service programs.
- Medicaid managed care plans.
- All of the health plans on federally facilitated exchanges.
Beyond that, there are three main changes to the prior authorization process that physicians and patients need to understand.
Perhaps most importantly, CMS will be shortening time frames for prior authorization decisions. Starting in 2026, payers will be required to provide a decision within 72 hours for expedited or urgent requests, and within seven calendar days for a standard request.
"We would have loved faster time frames, but this is a good first step," Dr. Ehrenfeld said. "We're certainly going to work with CMS with the hope that the agency is going to continue to update its policies in the future."
Also beginning in 2026, insurers will be required to share explanations of why prior authorization requests are denied. Metrics about how often insurers approve or deny prior authorization requests will also be made publicly available, creating more transparency and accountability in the process.
Starting in 2027, plans will be required to support an electronic prior authorization process that is embedded within a physician's EHR. That change will bring automation and efficiency to what is currently a manual, and oftentimes time-consuming process.
"I know firsthand the frustration that comes with having to spend hours on phone calls, playing phone tag, just to get approval for a treatment that I know, from my years of training, is the right thing for my patient," Dr. Ehrenfeld said. "So having direct integration of prior authorization into the EHR is going to significantly reduce the burden on physicians."
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Continuing to advocate for reform
Dr. Ehrenfeld called the final rule a huge win for patients and physicians, but he added there is still far more to advocate for at both the federal and state level.
“We want to expand these improvements to drug prior authorization," Dr. Ehrenfeld said. “And also at the national level, we're continuing to support the Improving Seniors Timely Access to Care Act, which would strengthen similar prior authorization reforms.”
More than 17 states have adopted comprehensive prior authorization reforms. Meanwhile, more than 70 different prior authorization bills of various types in more than 28 states have already been introduced at the state level this year. Dr. Ehrenfeld added that Cigna and UnitedHealthcare—two of the largest insurers in the country—have outlined voluntary efforts to reduce challenges caused by prior authorization.
"Momentum is building toward meaningful prior authorization reform," he said. "The bottom line is that insurers know the pressure is on. Policymakers know the pressure is on. And the progress, it's not as fast as we want, but it's happening, and we can feel good about that."
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