Federal rules have required health plans to publicly post their prior authorization requirements and outcomes since CMS finalized its Interoperability and Prior Authorization rule in 2024.
But a review by the American Medical Association found that many plans were meeting the letter of that requirement while making the information nearly impossible for patients and physicians to actually find or use — a gap CMS has now moved to close, according to an AMA news release shared with Becker’s Aug. 17.
Earlier this year, the AMA examined how 15 Medicare Advantage contracts were implementing the transparency provisions of CMS’s 2024 Interoperability and Prior Authorization final rule, which requires payers to publicly post prior authorization requirements and outcomes. The review found that plans appeared to comply on the surface while presenting disclosures in places and formats that made them difficult or impossible to find or use. Some posted hundreds of pages of billing codes without plain-language descriptions. Others buried required disclosures behind physician or member portals and deep within plan websites, reported mathematically impossible statistics and turnaround times without units, or omitted entire categories of care, including behavioral health and post-acute services, from public reporting.
“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” said AMA President Willie Underwood III, MD.
“Yet that is what we found when we examined how plans were implementing these transparency requirements. 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,” Dr. Underwood said.
The AMA documented the problems and recommended corrective action in a May 22 letter to CMS, followed by additional comments. CMS has now incorporated several of those recommendations into updated guidance. The agency defined what it means for prior authorization information to be publicly accessible, making clear that disclosures do not qualify if they are available only through password-protected portals or cannot be reached through ordinary navigation from a payer’s public-facing website. It also clarified that plans must publicly identify all medical items and services subject to prior authorization, addressing the omission of entire categories of care from some plans’ disclosures.
On usability, CMS said lists of procedure codes without plain-language descriptions do not satisfy the disclosure requirement, and it recommended a single, comprehensive list organized by uniform service categories, with CPT codes, plain-language descriptions and a machine-readable format. On accuracy, the agency clarified that every turnaround-time metric must include a unit of time, that median turnaround times of less than one day must be reported in hours rather than rounded to “0 days,” and it recommended that payers explain any data quality issues in their reporting.
“CMS has taken an important step toward making prior authorization information more transparent and usable,” Dr. Underwood said. “But the work is not finished. Patients and physicians need information that is accurate, accessible, understandable and comparable across health plans. You shouldn’t have to be a rocket scientist to figure out what the insurance companies are doing. The AMA will continue working with CMS to make sure transparency requirements actually deliver transparency.”
CMS has also recommended that payers follow a standardized prior authorization metrics reporting template to make disclosures easier to compare across plans, though the AMA is pushing CMS to make standardized reporting a requirement rather than a recommendation.
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