CMS Prior-Authorization Final Rule: Tactics to Fight Back and Win

CMS has recently finalized the Interoperability and Prior Authorization Final Rule to smoothen the complete process for prior authorization and payor requirements. New CMS rules impact the Medicare, commercial Medicare Advantage and other federally qualified plans. It is very crucial that you and your practice must be prepared and implement these changes correctly. You can fight back against the burden of prior authorizations without compromising your patient care or practice’s reimbursement.

Prior authorizations are a leading cause of denied claims - a problem that costs providers millions in lost revenue. Healthcare attorney and compliance expert Osato Chitou, ESQ., MPH, will provide you with tips and tricks that you can implement to cut through the red tape of prior authorizations. She will share the strategies your practice needs to speed up prior authorization approvals and reimbursement.

There is little information about how often prior authorization is used and for what treatments, how often authorization is denied, or how reviews affect patient care and costs. The KFF Issue Brief found that most (99%) Medicare Advantage enrollees are in plans that require prior authorization for some services. In addition, 84% of Medicare Advantage enrollees are in plans that apply prior authorization to a mental health service.

A recent report from the U.S. Department of Health and Human Services’ (HHS) Office of the Inspector General (OIG) found 13% of prior authorization denials by Medicare Advantage plans were for benefits that should otherwise have been covered under Medicare. The OIG cited use of clinical guidelines not contained in Medicare coverage rules as one reason for the improper denials, as well as managed care plans requesting additional unnecessary documentation.

The rule reaffirms Centers for Medicare & Medicaid Services (CMS) commitment to advancing interoperability and improving prior authorization processes. Through the provisions in this final rule, impacted payers are required to:

Implement and maintain certain Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data

Streamline prior authorization processes

Additionally, to encourage providers to adopt electronic prior authorization processes, the final rule also adds a new measure for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS.

Regarding prior authorization, the rule requires:

Prior Authorization Decision Timeframes: Impacted payers (excluding QHP issuers on the FFEs) are required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests.

Provider Notice, Including Denial Reason: Beginning in 2026, impacted payers must provide a specific reason for denied prior authorization decisions, regardless of the method used to send the prior authorization request. Such decisions may be communicated via portal, fax, email, mail, or phone. This provision does not apply to prior authorization decisions for drugs.

• Review updated Prior Authorization guidelines by CMS
• Understand prior authorization qualifications for faster payments
• Know the payor response timelines to speed up approvals
• Understand key reasons for delayed approval or rejection
• Review insurer-specific rules and process
• Identify factors slowing-down the process with actionable prior-authorization audits
  

• Prior Authorization Requirements
• CMS Interoperability and Prior Authorization Final Rule
• Patient Access API
• Provider Access API
• Payer-to-Payer API
• Prior Authorization API
• Improving Prior Authorization Processes
• Prior Authorization Metrics
• Ways to reduce the prior authorization burden
• Demonstrating successful implementation of Prior authorization Burden Reductions
• What Prior Authorization Method Should You Choose?
• Standard Electronic Transactions
• Payer Portal
• Multi-Payer Portal
• Fax
• Telephone
• Secure Email
• Rules and Requirements by Payer
• First Order of Business
• What CPT Codes Do You Use?
• What About the Drugs?
• How Will You Send It?
• How Will You Follow-Up?
• Prior Authorization Triggers
• Services and Procedures that Often Trigger Prior Authorization
• Category of medications that Trigger Prior Authorization
• Best Practices to Mitigate Denials
• Combating Denials

• Healthcare Executives and Administrators
• Compliance Officers & Lawyers
• Medical Practice Managers
• Physicians
• Nurses
• All Revenue Cycle Staff
• Practice Manager
• Compliance Team
• Financial Officers
• Department Managers
• Providers
• Clinical Staff
• Front Desk Team
• Every Member of the Practice/ System

Osato F. Chitou, ESQ., MPH, is the Founder and Principal Consultant of NMOC Healthcare Compliance Consulting, LLC, doing business as Compli by Osato which provides legal and compliance advisory services to Payors and Providers in receipt of Government Healthcare Funds. Ms. Chitou has a deep understanding of Government Healthcare Programs and focuses her services on Medicare and Medicaid Conditions of Participation, Private Equity backed Physician Groups, Payor Contracting, and Effective Compliance Programs.

She is a subject matter expert in Medicare DSNP, CSNP, ISNP, MMP, and PACE regulatory requirements. She presents nationally on issues related to Medicare Advantage risk adjustment, compliance requirements, and best practices related to operationalizing compliance. Ms. Chitou received her BA in Biological Anthropology from Boston University, her MPH from the University of North Carolina – Greensboro and her JD from Rutgers School of Law. Ms. Chitou is admitted to practice Law in New York, New Jersey, and the Supreme Court of the United States.