News & Advocacy

OAR Supports Federal Prior Auth Reforms, Suggests Modifications

posted: March 13, 2023

Recommendations address challenges for patients, practices, and providers.

In a March 13, 2023, letter to the Centers for Medicare & Medicaid Services (CMS), President Elisabeth S. Roter, MD, expressed support for the agency’s prior authorization (PA) reform efforts and endorsed several recommendations issued by the American Medical Association, including appeals for CMS to: 

• Leverage a regulatory pathway that will apply to all health plans when mandating PA-related implementation guides and transaction standards in any future rulemaking.
• Explore the need to designate an electronic transaction standard for drugs covered under a medical benefit.
• Strengthen the requirement for health plans to provide a specific reason for a PA denial to ensure that the information is understandable and outlines clear, actionable next steps.
• Shorten the required PA processing timeframes to 48 hours for standard PAs and 24 hours for expedited PAs to protect patient safety.
• Require plans to report PA program metrics at a more granular level and require posting of the information on a centralized website (e.g., CMS webpage) to enable easy retrieval by physicians and patients.
• Include offering “gold card” programs as a measure in star quality rating programs.
• Create a formal oversight, audit, and enforcement process to promote accountability and ensure appropriate implementation of the rule’s provisions, when finalized.
• Increase patient access to their medical information through health plan-enabled and maintained application programing interfaces (APIs).
• Require health plans to honor the PA approvals from the patient’s previous health plan to support continuity of care and protect patients from potentially dangerous disruptions in ongoing therapy.
• Oppose adding burden to physicians and their staff by linking electronic PA requirements to CMS’ Quality Payment Program.

Read the Full Letter