Cracking down on hidden prior auth rules: What’s new and what’s needed

The U.S. Centers for Medicare & Medicaid Services (CMS) have issued guidelines that strengthen enforcement of federal prior authorization (PA) requirements.

It’s welcome news, although more action is needed to clarify how health insurers and payers consider the preapprovals that physicians make for their patients, according to the American Medical Association (AMA).

CMS's 2024 Interoperability and Prior Authorization final rule requires payers to publicly post prior authorization requirements and outcomes. AMA announced researchers earlier this year examined how 15 Medicare Advantage contracts were doing so.

AMA found “a consistent pattern.” On the surface, many plans appeared to comply with the rule. In reality they buried the information in ways not easy to find for physicians and patients.

“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” AMA President Willie Underwood III, M.D., M.Sc., M.P.H., said in a statement.

“Yet that is what we found when we examined how plans were implementing these transparency requirements,” Underwood said. “One plan posted an 832-page list of billing codes without a word of plain English. Others buried required information behind portals. Another published numbers that didn’t add up — and acknowledged that its data should ‘not be relied upon.’ In other words, thank you for reading this. The information may or may not be true.”

AMA documented the problems in a May 22 letter to CMS and followed with additional comments. The association said CMS has now incorporated several of AMA's recommendations into its guidance.

This slideshow presents AMA findings about prior authorization disclosures, and what more CMS should do to improve payer PA publications for physicians and patients.