Under CMS' recently finalized prior authorization rule, certain payers will be required to send decisions within 72 hours for urgent requests and seven calendar days for standard requests.
American Medical Association President Jesse Ehrenfeld, MD, said in a Jan. 25 article on the organization's website that this is "arguably the most important change because it's going to save lives."
Dr. Ehrenfeld said he would have liked to see faster time frames — 24 hours for urgent requests and 48 hours for standard — but call this "a good first step."
"And we're certainly going to work with CMS with the hope that the agency is going to continue to update its policies in the future," he said. "It's also important to mention that enforcement of these policies, particularly around the Medicare Advantage payers, could potentially include sanctions from CMS, monetary penalties. So there is teeth behind this legislation and this rulemaking to make sure that we have enforcement and that the insurers play ball."
From here, Dr. Ehrenfeld wants to see the changes expand to drug prior authorization. He said the AMA is continuing to push the Seniors Timely Access to Care Act. That legislation passed through the House of Representatives in 2022 but stalled in the Senate "due to a flawed $16 billion cost estimate from the Congressional Budget Office."
He said the final rule could mean a significant drop in the agency's $16 billion cost estimate and with it, increased odds of passage. The bill was reintroduced in 2023 and passed out of the House Ways and Means Committee in July.