Thursday, April 23, 2026

CMS issued a proposed rule to streamline prior authorization for Part D and MA drugs, mandating payer response decisions within 72 hours for urgent requests and 7 days for standard ones. It would require payers to build and maintain a 'Patient Access API' to share PA data and decisions programmatically. The rule targets a leading cause of prescription abandonment and delayed therapy starts. The comment period closes June 13, 2026. Monitor for the final rule's interoperability and timeline requirements, which would reshape pharmacy benefit workflows.

UnitedHealthcare announced it will eliminate prior authorization requirements for most services for rural providers participating in its new 'Rural Health Financial Stability Program'. This applies to UHC commercial, Medicare Advantage, and Medicaid plans for in-network rural hospitals and affiliated clinics. The move aims to reduce administrative burden and accelerate payments. Eligibility is based on location and participation in the program. Rural practices contracting with UHC should contact their account representative immediately to confirm eligibility and understand which service codes are now exempt from PA.

CMS and the FDA jointly announced the RAPID Coverage Pathway, a new process to accelerate Medicare coverage for FDA-designated breakthrough devices. The pathway allows for parallel review and aims to reduce the lag between FDA approval and Medicare reimbursement decisions from years to potentially months. It applies to a select group of devices that address unmet medical needs. For practices, this means certain advanced diagnostics and therapeutics may become billable to Medicare sooner after market entry. The first devices under this pathway are expected in 2027.

CMS and the FDA jointly announced the RAPID Coverage Pathway, a new framework to accelerate Medicare coverage for FDA-designated 'breakthrough' medical devices. The voluntary program, detailed in a press release on April 23, 2026, aims to reduce the lag between FDA approval and Medicare reimbursement decisions. CMS will begin accepting voluntary submissions under the RAPID program later in 2026. For practices, this signals that new, high-cost specialty devices may reach Medicare patients faster, potentially affecting prior-authorization and coding workflows. Monitor CMS announcements for the specific go-live date and initial list of eligible device categories.

A report to Congress details significant care delays for seniors under a CMS demonstration project testing AI for prior authorization. The program, known as WISER, is active in Washington state and uses an automated system for Medicare Advantage prior auth. Hospitals reported the AI frequently denies or 'pends' clinically appropriate care, forcing providers into lengthy manual appeals. The report, cited by Senator Patty Murray, concludes the pilot has 'failed to reduce burden' and instead created new barriers. This adds evidence to the debate around AI in utilization management, highlighting risks for practices that depend on automated payer systems.