On prior auth, CMS responds to AMA concerns

CHICAGO - The American Medical Association (AMA) today welcomed updated guidance from the Centers for Medicare & Medicaid Services (CMS) that strengthens enforcement of federal prior authorization transparency requirements, addressing concerns the AMA raised about how health plans were making required information available to patients and physicians.

The AMA alerted CMS to widespread problems with health plans' public disclosures of prior authorization requirements and outcomes. Rather than making information readily accessible, many plans posted disclosures that were difficult to find, hard to comprehend or incomplete. CMS' updated guidance addresses several of these concerns and provides greater clarity for patients seeking information about health plans' prior authorization policies.

"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, MSc, MPH.

"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."

The AMA documented these practices, brought them to CMS, and the agency acted. The AMA is grateful for the updated guidance.

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 AMA's review revealed a consistent pattern: On the surface, many plans appeared to comply with the rule while presenting disclosures in places and formats that made them difficult or impossible to find or use. Plans posted hundreds of pages of billing codes without plain-language descriptions, buried required disclosures behind physician or member portals and deep within plan websites, reported mathematically impossible statistics and turnaround times without units, and omitted entire categories of care -- including behavioral health and post-acute services -- from public reporting.

The AMA documented these problems and recommended specific corrective actions in a May 22 letter (PDF) to CMS, followed by additional comments (PDF).

CMS has now incorporated several of the AMA's recommendations into its guidance.

Specifically, the guidance:

• Defines what it means for prior authorization information to be publicly accessible. CMS makes clear that disclosures are not publicly accessible if they are available only through password-protected portals or cannot be reached through ordinary navigation from a payer's public-facing website.
• Clarifies disclosure of all medical items and services subject to prior authorization. CMS specifies that plans must publicly identify all medical items and services requiring prior authorization, addressing the omission of entire categories of care from plan disclosures.
• Clarifies that prior authorization disclosures must be understandable. CMS explicitly says lists of procedure codes without plain-language descriptions do not satisfy the requirement and recommends a single, comprehensive list organized by uniform service categories, with CPT codes, plain-language descriptions and a machine-readable format.
• Improves accuracy and reliability of reported data. CMS clarifies that every turnaround-time metric must include a unit of time and requires median turnaround times of less than one day to be reported in hours rather than rounded to "0 days." The agency also 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," 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."

The AMA is urging CMS to build on the new guidance by addressing several remaining gaps in the federal transparency framework:

• Define prior authorization broadly enough to capture rebranded practices. CMS should define prior authorization based on how the process functions, regardless of whether a payer calls it "prior authorization," "precertification," or "advance notice," or delegates the process to a third-party utilization management vendor.
• Make prior authorization information available at the point of enrollment. CMS should link directly from plan pages on Medicare Plan Finder and HealthCare.gov to their prior authorization requirements and performance metrics, and should require states to include the same links in Medicaid and CHIP plan-comparison and enrollment tools.This would give consumers the information they need to compare plans before choosing coverage.
• Standardize prior authorization reporting. CMS should require standardized templates for prior authorization service lists and performance metrics, rather than merely recommending standardized reporting. Consistent formats would make information easier for patients and physicians to understand and compare across plans.

Patients and physicians can share their experiences with care delays and denials at FixPriorAuth.org.