The US Government has finalised a rule that mandates health insurers offering government-supported plans to speed up prior authorisation for medical services.
The CMS Interoperability and Prior Authorisation Final Rule (CMS-0057-F) set forth by the Centers for Medicare & Medicaid Services (CMS) of the Department of Health and Human Services (HHS) aims to streamline the prior authorisation process.
The move is expected to significantly reduce the administrative burden and improve efficiency, with an estimated $15bn in savings over the next ten years.
The policy mandates that health insurers offering government-backed plans such as Medicare for people aged 65 years and above and Medicaid for low-income individuals must now adhere to certain time targets.
Starting in 2026, insurers are required to process urgent prior authorisation requests within 72 hours while standard requests are within seven calendar days.
According to the CMS, this represents a substantial reduction in decision time frames, which for some requests is currently twice as long.
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By GlobalDataCMS administrator Chiquita Brooks-LaSure said: “CMS is committed to breaking down barriers in the healthcare system to make it easier for doctors and nurses to provide the care that people need to stay healthy.
“Increasing efficiency and enabling healthcare data to flow freely and securely between patients, providers and payers and streamlining prior authorisation processes supports better health outcomes and a better healthcare experience for all.”
Furthermore, the rule stipulates that insurers must provide explicit reasons for any denials of prior authorisation requests.
This transparency is intended to aid healthcare providers and patients in understanding the grounds for denial, thereby simplifying the process of resubmission or appeal.
HHS Secretary Xavier Becerra said: “Too many Americans are left in limbo, waiting for approval from their insurance company.
“The Biden-Harris Administration is announcing strong action that will shorten these wait times by streamlining and better digitising the approval process.”
