Prior authorization has been a consistent pain point for revenue cycle leaders, but hopefully not much longer.
The Centers for Medicare & Medicaid Services rule for the annual review of prior authorization policies went into effect on January 1. It’s too early to know if the rule, which will also ensure that policies stay in place for as long as a patient needs a service, may offer some relief to providers and financially strained health systems.
Here are some previous HealthLeaders articles to get you up to speed.
Is Prior Auth Automation the Key to Improved Financial Performance?
Prior authorization impacts patient access to care and provider reimbursement, making it an important part of the revenue cycle. With reasons for denials stemming from clerical issues or insufficient documentation, some organizations have embraced automation as a solution and seen results. Others, not so much.
Medicare Advantage Insurers Denied Over 2M Prior Authorization Requests in 2021
A report by Kaiser Family Foundation found that over two million out of 35 million prior authorization requests were denied by Medicare Advantage in 2021. Adding to a December 2022 proposal, CMS proposed a new rule to strengthen prior authorization protections, including having policies reviewed annually.
Groups Commend Prior Authorization Requirements in Medicare Advantage Final Rule
Organizations like the American Hospital Association, American Medical Association, Medical Group Management Association, and Better Medicare Alliance voiced their support of CMS’ proposed rule.
Prior Authorization Requirement in Medicare Advantage Have Gone Up, Not Down
The Medical Group Management Association conducted a poll among 601 medical groups on their experiences with prior authorization and Medicare Advantage. Results found issues had gotten worse over the last year, and less than 1% reporting requirements had decreased.
Majority of States Have Introduced Prior Authorization Reforms
Prior authorization issues began getting attention from state governments, with 90 reform bills being introduced in 30 states.
Jasmyne Ray is the revenue cycle editor at HealthLeaders.