From CMS finalizing a rule aimed at streamlining the process to UnitedHealthcare launching a gold-card program, here are four key prior authorization updates Becker's reported in 2024:
1. A new CMS rule aiming to streamline Medicare Advantage and Part D prior authorizations took effect Jan. 1. CMS issued the final rule in April 2023 and requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary. It also requires coordinated care plans to provide a minimum 90-day transition period when a beneficiary undergoing treatment switches to a new MA plan. During this period, the new plan cannot require prior authorization for the active course of treatment.
2. CMS finalized a rule Jan. 17 to streamline the prior authorization process and improve the electronic exchange of health information that it estimates will save $15 billion over 10 years. Beginning primarily in 2026, certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.
3. UnitedHealthcare's national prior authorization gold-card program went into effect Oct. 1. Providers do not have to apply for the gold-card program but must meet certain eligibility requirements:
- Be in-network for at least one UnitedHealthcare commercial, individual exchange, Medicare Advantage or community (Medicaid) plan.
- Meet a minimum annual volume of at least 10 prior authorizations per year for two consecutive years across gold-card-eligible codes.
- Have a prior authorization approval rate of 92% or more across all gold-card eligible codes for each of the review years.
4. Several states passed laws in 2024 reforming the prior authorization process, according to the American Medical Association. The AMA said the specifics of the laws vary by state, "but broadly speaking they aim to cut the growing volume of prior authorization requirements, reduce patient care delays, increase the data that must be publicly reported and improve transparency about which medications and procedures require prior authorization."