US government establishes rule to expedite insurance approvals
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January 17 (Reuters) – A rule requiring health insurers to set timelines for the prior authorization process for patients requesting approval for medical services under government-backed insurance plans was finalized by U.S. President Joe Biden’s administration on Wednesday.
The rule will primarily take effect in 2026, according to the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services.
The regulation covers health insurance providers who offer government-backed insurance programs, including Medicaid for low-income people and Medicare for people 65 and older.
Prior authorizations have been criticized by some physician organizations in recent years, who claim that they add to doctors’ paperwork and result in restrictive coverage in certain circumstances.
Health and Human Services Secretary Xavier Becerra stated, “It is crucial that a procedure be performed on a patient as soon as a doctor recommends it.”
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“Too many Americans are left in limbo, waiting for approval from their insurance company.”
According to the new regulation, requests requiring prior authorization must be answered within 72 hours for urgent requests and within seven calendar days for regular, non-urgent requests.
The CMS reports that the new standard request timeline reduces the current decision time in half for some insurers.
Additionally, it mandates that all payers provide a clear explanation for any prior authorization request that they deny; this will facilitate future resubmissions of the request and, if necessary, appeals.
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