1. In its recently proposed reforms to the Medicare Advantage and Part D programs for 2026, CMS is looking to “address concerns about the overuse of prior authorization” by clearing up definitions for internal coverage criteria, creating stricter transparency requirements for payers, ensuring enrollees are informed about their rights to appeal and collecting more data on initial coverage decisions and appeals.
2. A bipartisan group of legislators has also reintroduced the Improving Seniors’ Timely Access to Care Act, which would reform prior authorization requirements in Medicare Advantage plans. ACG has developed an advocacy tool to support this legislation.
3. The proposed changes come after sustained outcry from physicians and physician advocacy groups, 61% of whom said that patients frequently abandoned a recommended treatment due to prior authorizations in Medscape’s “‘They’re Awful and Impede Patient Care’: Medscape Physicians and Prior Authorizations Report 2024.”
The report surveyed 1,073 physicians between March 1 and May 20, 2024. These are the changes in the prior authorization process that physicians said they supported in the report:
Uniform procedures among payers — 51%
Greater automation on providers’ end — 19%
A central database of procedures — 12%
Other — 9%
More e-filing/e-delivery options on payers’ end — 8%
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