Monday, April 27, 2026

CMS published a sweeping proposed rule on April 14 to implement prior authorization interoperability requirements from the 2021 CAA. It mandates Medicare Advantage, Medicaid managed care, CHIP, and QHP issuers to build and maintain a Patient Access API. The rule targets standardizing prior authorization processes and data exchange. This marks the start of a multi-year rebuild of the operating model. The comment period is open; track the docket (CMS-2025-XXXX) for the final rule expected late 2026, with implementation likely staggered through 2027.

A federal report and senator's letter reveal a CMS AI prior authorization pilot in Washington state is causing significant care delays for Medicare beneficiaries. The automated system, aimed at streamlining reviews, is instead flagging high volumes of routine services for manual review, creating backlogs. For practices with Medicare patients in Washington, this means longer wait times for authorization approvals on services like imaging and procedures. Escalate any delayed CMS prior auths to your provider representative immediately and document patient impact for potential appeals based on timeliness standards.

Major payers UnitedHealthcare, Aetna, and Cigna report an 11% aggregate reduction in prior authorization requirements, attributing it to ongoing industry standardization efforts. The claims follow a 2025 commitment to align requirements for certain high-volume services. This data suggests a gradual, payer-driven shift away from prior auth for some routine services. However, the reduction is not uniform across specialties or plans. Monitor your denial and auth reports for these payers to identify any corresponding decrease in administrative burden or changes in the types of services requiring review.

CMS and the FDA announced the RAPID Coverage Pathway, a new expedited process for Medicare coverage of FDA-designated breakthrough medical devices. The program aims to reduce the gap between FDA approval and Medicare coverage decisions. It requires manufacturers to engage with CMS early and submit real-world evidence plans. This could accelerate patient access to novel technologies but also introduces a new evidence-generation requirement. Track device manufacturers' announcements to anticipate which novel therapies might arrive sooner for your Medicare patients.

Representatives Pramila Jayapal and Ro Khanna introduced a bill to prohibit the use of prior authorization for any item or service covered under Medicare Advantage plans. The legislation frames prior authorization as a barrier to care that disproportionately impacts seniors. While passage is uncertain, the bill signals growing legislative pressure on MA prior auth practices. Monitor the progress of this bill, H.R. [number pending], as it could herald a major operational shift for practices with significant MA patient panels if it gains momentum.