CMS Proposes Rule to Expand Access to Health Information and Improve the Prior Authorization Process

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on December 6, 2022 that, among other things, proposes improvements to the prior authorization processes used by Medicare Advantage plans. The proposed rules is intended to encourage the electronic exchange of health care data as it relates to the prior authorization process. CMS is also proposing policies to make the process more efficient and transparent. Proposed policies include requiring payers to include a specific reason for denial of a prior authorization, shortening prior authorization decision timeframes, and public reporting of certain prior authorization metrics by payers.

Formal comments on the rule can be submitted through 3/13/2023 at the Federal Register website here.

The CMS press release can be found here. The CMS fact sheet can be found here.

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Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a Master’s degree in Management Information Systems from the University of Illinois, Springfield.

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.