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Prior authorization is a tool used by commercial health plans to drive down healthcare costs and prevent bad actors from prescribing unnecessary medications or services. However, the process is known to be tedious, often slow, overused and can incorrectly deny coverage for necessary medical care. To address these concerns, the U.S. Centers for Medicare & Medicaid Services (CMS) has put forth a proposal to accelerate and strengthen the prior authorization process in federally-sponsored health insurance programs through implementing many of the provisions included in the Improving Seniors Timely Access to Care Act, legislation Senator Rubio supported in the 117th Congress. However, the proposed rule omits key solutions proposed in the legislation that are critical to improving the process.

U.S. Senators Marco Rubio (R-FL), John Thune (R-SD), and their colleagues sent a letter to U.S. Secretary of Health and Human Services Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure urging the agency to implement all of the provisions of the bill in their prior authorization final rule.  

• “We urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans.”

• “We also urge CMS to expand on these proposed rules by: (1) establishing a mechanism for real-time electronic prior authorization (e-PA) decisions for routinely approved items and services; (2) requiring that plans respond to PA requests within 24 hours for urgently needed care; and (3) requiring detailed transparency metrics.”

The full text of the letter is below.

Dear Secretary Becerra and Administrator Brooks-LaSure: 

We write to thank the U.S. Centers for Medicare & Medicaid Services (CMS) for taking action toward ensuring timely access to health care by proposing rules to streamline prior authorization (PA) protocols for individuals enrolled in federally-sponsored health insurance programs, including Medicare Advantage (MA) plans.1, 2, 3 We urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans. We also urge CMS to expand on these proposed rules by: (1) establishing a mechanism for real-time electronic prior authorization (e-PA) decisions for routinely approved items and services; (2) requiring that plans respond to PA requests within 24 hours for urgently needed care; and (3) requiring detailed transparency metrics. 

We appreciate that the rules CMS proposed in December 2022 concerning PA attempt to strike a balance between program integrity and patient access to care. While we agree that PA, when used appropriately, is an important tool for payers to manage costs and ensure program integrity, we support CMS’s efforts to protect beneficiaries, increase transparency around PA requirements, and streamline this process for patients, providers, and health plans. 

We are pleased that these proposed rules align with the bipartisan, bicameral Improving Seniors’ Timely Access to Care Act, which proposes a balanced approach to prior authorization in the MA program that would remove barriers to patients’ timely access to care and allow providers to spend more time treating patients and less time on paperwork. Specifically, both the legislation and CMS’s recent proposals would: 

? establish an e-PA process for MA plans; 

? accelerate PA decision time frames; 

? reduce the administrative burden for both providers and health plans; 

? increase transparency around PA requirements and clinical information needed to support decisions; and 

? expand beneficiary protections to improve patient experiences and outcomes. 

We encourage CMS to build on the e-PA proposal in the final rule by incorporating a mechanism for real-time decisions for routinely approved items and services. This mechanism would improve patient care and reduce provider burden while avoiding unnecessary delays. Hundreds of organizations representing patients, physicians, hospitals, and other health care experts have put their support behind an e-PA proposal that includes a real-time process for items and services that are routinely approved. 

As you know, the health insurance industry has been actively working towards real-time decisions through automation and artificial intelligence from end-to-end.4 The software market for providing these services is competitive, offering several platforms for health care providers and payers where a real-time decisions tool is available today. Based on industry growth (due to market demand), robust evidence continues to demonstrate that implementing real-time decisions produces cost savings for health care providers and health plans.5 

We also encourage you to build on the proposed rule’s goal of shortening decision timeframes by reducing the deadline for responding to expedited prior authorization requests from 72 hours to 24 hours to ensure urgently needed care is not delayed. We are concerned that delaying care for up to three days could jeopardize a patient’s life, health, or ability to regain maximum function. Further, we ask that you build upon the goal of increasing transparency by aligning the final rule’s data collection requirements with the information reporting requirements outlined in Section 2 of the Improving Seniors’ Timely Access to Care Act.

These policies: (1) a mechanism for real-time prior authorization decisions for routinely approved services, (2) a deadline of 24 hours for MA plans to respond to prior authorization requests for urgently needed care, and (3) requiring detailed transparency metrics are in line with the Improving Seniors’ Timely Access to Care Act, which has received significant bipartisan support from members of Congress and endorsements from more than 500 organizations engaged in this work.6 

We urge you to finalize these important updates to prior authorization processes in a manner that reflects the Improving Seniors’ Timely Access to Care Act as quickly as possible in order to improve access to health care for patients. We appreciate your engagement on these policies and encourage you to continue working on policies that increase the efficiency and transparency of the process for patients to receive care. 

Thank you again for your dedication to this matter. 

Sincerely,