CLL Society has been a long-time advocate for easier and faster ways to manage through insurance company hurdles like prior authorization (PA).
This month, the Centers for Medicare and Medicaid Services (CMS) finally established an e-prior authorization system that should cut in half the time it takes plans to process prior authorization requests.
CMS says plans will have to respond to urgent requests within 72 hours and non-urgent requests within a week. There’s a bill in Congress that calls for responses in real time but critics of the bill say it’s too costly so it has not made progress.
Insurance companies will also have to explain the rationale behind their decision-making and publicly post their prior authorization metrics, meaning how often they put patients through PAs, how they’re resolved, etc. Posting the rationale for a PA decision should make it a lot easier for a doctor to appeal a decision.
This action does not extend to PAs on drugs at this time, although we hope this will come soon from either CMS or Congress. For now, it applies to surgeries and other procedures, doctor visits and other services your health plan covers.