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Getting the latest healthcare news for you
Getting the latest healthcare news for you
CMS has updated its prior authorization transparency guidance after the AMA found that many health insurers were technically "complying" while burying required disclosures behind portals, posting hundreds of pages of billing codes with no plain-language descriptions, and even publishing data that didn't add up. The new guidance closes key loopholes — but the AMA says more work remains, including standardized reporting templates.
CMS has strengthened its prior authorization transparency guidance following a review by the American Medical Association (AMA), which found that many Medicare Advantage plans were falling short of the spirit of the 2024 Interoperability and Prior Authorization final rule. While plans appeared compliant on the surface, the AMA's examination of 15 Medicare Advantage contracts revealed a troubling pattern: disclosures buried behind password-protected portals, 800+ page billing code lists with zero plain-English explanations, mathematically impossible statistics, and entire care categories — like behavioral health and post-acute services — omitted from public reporting entirely.
The updated CMS guidance now closes several of these gaps. Plans must publicly identify all services requiring prior authorization, include time units in all turnaround metrics (reporting sub-day times in hours, not "0 days"), and ensure disclosures are reachable through ordinary website navigation — not hidden behind member or physician portals.
Key Takeaways:
Why it matters: Prior authorization delays and denials are a top frustration for both physicians and patients. This guidance update is a meaningful step toward real accountability — but without standardized reporting formats and broader definitions, insurers still have room to obscure the full picture.
