Thursday, April 16, 2026

CMS issued a proposed rule to establish new interoperability and prior authorization standards for Medicare Advantage, Medicaid managed care, and CHIP plans, specifically targeting prescription drugs. The rule aims to standardize prior auth data exchange for Part D medications. The comment period closes in June 2026. If finalized, this could require practice EHRs and clearinghouses to support new API-based transaction flows for drug authorizations in 2027.

CMS released the annual proposed rule for the Hospital Inpatient Prospective Payment System for FY 2027. The rule includes the usual updates to payment rates, MS-DRG weights, and quality reporting programs. For independent practices with hospital-based services, the annual wage index adjustments and proposed changes to graduate medical education payments are the key operational items. The comment period closes in June 2026. Monitor the final rule, expected in August, for finalized rate changes that will affect facility fees and bundled payment contracts.

CMS proposed expanding its mandatory bundled payment model for hip and knee replacements, the Comprehensive Care for Joint Replacement (CJR) model, nationwide. The model holds hospitals financially accountable for the cost and quality of an episode of care, from surgery through 90 days post-discharge. If finalized, this expansion will affect orthopedic surgeons and affiliated practices in regions not previously subject to CJR, potentially altering referral patterns and care coordination agreements with participating hospitals. The proposal is part of the broader FY 2027 IPPS rule.

CMS and the FDA jointly launched the RAPID Coverage Pathway, a new program designed to accelerate Medicare coverage of FDA-designated breakthrough medical devices. The initiative aims to synchronize the FDA approval and CMS national coverage determination processes to reduce the traditional lag, which can be several years, between device approval and Medicare reimbursement. For practices, this signals faster patient access to novel technologies like advanced diagnostics and implantable devices, but also introduces new coding and coverage education requirements as these products reach the market.

Representatives Pramila Jayapal and Ro Khanna introduced legislation to ban the use of prior authorization in Medicare Advantage programs. The bill aims to eliminate a major source of care delays and administrative burden for providers treating MA patients. While its passage is uncertain, the proposal reflects growing political scrutiny of payer utilization management practices and adds momentum to broader prior-auth reform efforts. Track the bill's progress; its advancement would fundamentally change authorization workflows for a significant portion of the patient population.