Payer advocacy

CMS issued new regulations on prior authorization regulation for Medicare, Medicare Advantage, Medicaid, CHIP plans. While the regulations (PDF) do not apply to private, commercial health plans, and ERISA plans, the Academy anticipates that many private health plans will adopt similar policies.

While the Academy advocated for the PA reforms to include medications in addition to services, the new regulations do not apply to drugs of any type. However, CMS has acknowledged the strong support for such reforms and will consider them in future rulemaking. Overall, these reforms lay the foundation for improved prior authorization for patients and physicians.

The Academy has advocated tirelessly for prior authorization reforms. Many reforms we fought for were included in the regulations, which take effect in 2026. These include:

Shorter deadlines for health plans to respond to prior authorization (PA) for urgent and non-urgent requests.

• 72-hour deadline for expedited PA requests

• 7-day deadline for standard PA requests

Increased transparency of health plans’ use of PA.

• Access to policies and procedures used by Medicare Advantage plans for PA determinations.

• Increased transparency for clinical information needed to support PA approvals. Impacted payers must provide a specific reason for denied PA decisions.

Public prior authorization metrics.

• Payers must publicly report certain PA metrics annually, including approval/denial rates and average processing time.

Improvements in exchange of medical documentation.

• By 2027, CMS will require covered payers to implement and maintain an Application Programming Interface (API) that allows a physician to connect and conduct PA using their EHR. This API must contain a list of covered items, services, and documentation requirements for PA approval. The API must also communicate whether the payer approves, denies, or asks for more information about the PA request. The federal government is currently working on complementary regulations for EHR developers.

• The Academy encouraged CMS to adopt principles outlined in our position statement on Electronic Documenting and Administrative Burdens to facilitate patient access and alleviate administrative burdens. The Academy urged payers and EHR vendors to work with physicians towards simplified and transparent sharing of medical data, through a common programming language.

Impact on MIPS Interoperability.

The final regulation represents a win for administrative simplification. CMS is adding a new measure to the MIPS Promoting Interoperability (PI) performance category. Starting in 2027, MIPS eligible clinicians will report a “yes/no” attestation stating they have sent at least one electronic PA annually to a payer via their EHR. CMS’s original proposal would have required physicians to manually track and report each electronic and paper-based PA. Responding to our advocacy, CMS removed the manual reporting requirements and extended the compliance timeline to 2027.

Our fight continues for PA drug reforms.

While the Academy advocated for the PA reforms to include medications in addition to services, the new regulations do not apply to drugs of any type. However, CMS has acknowledged the strong support for such reforms and will consider them in future rulemaking.

As noted, these reforms impact medical services and not drugs. The Academy continues to advocate for prior authorization reforms and access to drugs.