Prior Authorization Takes a Leap Forward in CMS Regulation

The Centers for Medicare & Medicaid Services (CMS) have taken a bold step by mandating a standard for prior authorization. I talked to Nikki Henck, Senior Director of Utilization Management at Sagility, about the implementation and potential impact of this proposed requirement, which, if finalized, will be enacted in January 2026. The Dilemma of Prior Authorization Prior authorization, also known as a pre-approval, strikes fear into both patients and providers. In a 2022 American Medical Association physician survey, 88% of providers said that the burden of doing prior authorization was high or extremely high. Another survey by the Medical Group Management Association (MGMA) ranked prior authorization as the largest regulatory burden on doctors. Yet in a traditional fee-for-service payment model, prior authorization by payers is absolutely crucial. Without it, overtreatment would skyrocket, causing pain to patients and bankrupting the payers. Prior authorization exists in many nationalized health systems, not just in the U.S. In theory, fee-for-value would eliminate the need for prior authorization because everyone should be aligned on a common goal of keeping the patient well while minimizing treatment. But that is an ideal far off in the future. In 2022, more than 66 million prior authorization requests were submitted manually by phone or fax, according to the Council for Affordable Quality Healthcare. A manual submission often occupies more than 20 minutes of staff t...
Source: EMR and HIPAA - Category: Information Technology Authors: Tags: Administration Health IT Company Healthcare IT Interoperability Regulations AMA CMS Electronic Prior Authorization FHIR Nikki Henck Prior Authorizations Sagility Source Type: blogs