How the Prior Authorization Process May Be Changing for the Better

Prior authorization can be a frustrating step in revenue cycle management (RCM). Payers often aren’t forthcoming with critical information about coverage eligibility, which can obfuscate financial responsibility on the part of the patient. Thankfully, a new rule could change this. Discover how prior authorization may be changing for the better.

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Prior authorization is a key step in revenue cycle management (RCM) and a quintessential part of ensuring claims are properly submitted to payers. Unfortunately, the prior auth process can be cumbersome with little transparency — until now. Thanks to a proposed rule update from the Centers for Medicare and Medicaid Services (CMS), providers may finally get the insight they need to approach prior authorization deftly.

Prior authorization under scrutiny

Prior authorization determines which procedures, treatments, or medications are covered by insurance vs. those for which a patient is directly responsible. This isn’t always a simple process. A lack of transparency and guidelines surrounding prior authorization often results in frustration among healthcare professionals.

The increasing number of procedures, medications, and services requiring prior authorization — coupled with varying requirements and documentation across different insurance providers — has created a convoluted and time-consuming process. The absence of clear communication channels and standardized protocols further exacerbates the problem.

Healthcare providers are left grappling with administrative burdens, leading to delays in patient care and an unnecessary strain on resources. Hopefully, this is about to change.

Proposed changes to prior authorization

Proposed changes to the prior authorization process by the CMS aim to address longstanding challenges. They introduce several key modifications to enhance transparency, efficiency, and communication, including:

  • Under the new rules, payers would be required to offer a specific reason when denying an authorization request. This requirement aims to provide clearer explanations about the basis for denial.
  • The proposed changes mandate certain authorization metrics to be publicly reported. This transparency initiative intends to hold payers accountable for their prior authorization practices.
  • CMS has proposed faster decision timelines for urgent and non-urgent requests. Payers would be expected to make decisions within 72 hours for urgent requests and within seven days for standard, non-urgent requests.
  • The changes emphasize the need for improved data exchange. CMS aims to facilitate the exchange of relevant patient information between providers and payers to streamline the prior authorization process.

These proposed changes to prior authorization have the potential to benefit both patients and providers.

A better approach to filing claims

The new rules proposed by the CMS offer significant advantages for providers, particularly in terms of creating clarity and efficiency at the earliest points of the RCM process. Better prior authorization results in fewer chances for miscommunication about coverages, improved confidence in understanding payer responsibility, enhanced patient experiences thanks to illumination of coverage, and quicker verification for faster service and billing.

Above all, an improved prior authorization process sets a confident tone for patients and providers. Patients will know their financial responsibility upfront, and providers will know how to proceed when the time comes to bill accordingly.

A much-needed overhaul

Changes to the prior authorization process open a new realm of opportunity for providers seeking to enhance the patient experience and better manage RCM at its earliest stages. The ability to clarify denials, gain insight into coverage metrics, and increase the speed of decisions will allow providers to serve patients better and faster. The new CMS rule could be a big win for patients and providers alike.

Learn more about prior authorization changes at