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Final CMS rule curbs prior authorization burdens for Medicare Advantage enrollees

by John R. Fischer, Senior Reporter | April 13, 2023

Commercial insurers have also announced that they will simplify prior authorization processes.

UnitedHealthcare says it will reduce prior authorizations for procedures supported by evidence-based guidelines for MA, commercial, and Medicaid plans, starting in Q3 2023, and launch a national Gold Card Program in early 2024 that will eliminate preapproval processes for most procedures. It will continue to require prior authorization for investigational, experimental or unproven procedures, and those that pose risks to patient safety.

The American College of Radiology has proposed replacing prior authorization with automated clinical decision support systems that make decisions based on physician-developed appropriate use criteria guidelines.

“EMR-embedded systems remove the need to hire employees specifically to navigate the laborious prior authorization maze in use today,” it said. “The systems are widely used today, and all evidence shows their effectiveness in ordering the correct advanced imaging study in a matter of seconds with minimal disruption in clinicians’ time.”

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