What Does Medicare’s New Rule Mean for Prior Authorization?

Q. My wife and I are currently on Medicare. Something problematic that we have experienced is that when we go to a doctor’s appointment and need a referral, we cannot go to a specialist or get some much-needed medications without prior approval. It may take days, weeks, or even months for a necessary test or medical procedure to be scheduled or a critical prescription to be filled because the referring/prescribing doctor needs to first obtain prior authorization from Medicare. This often delays us from receiving necessary care or medication when we need it most. Is there anything being done to alleviate this problem?

A. Yes, there is! First, let me reflect on a case study that describes the magnitude of the problem of prior authorizations. Dr. Resnick, a dermatologist, was treating a patient with severe eczema — a skin condition that can cause painful, itchy rashes from head to toe. The doctor found a medicine that works well for this patient, and it changed that patient’s life for the better. A year later, Dr. Resnick received a note from the insurance company that said that a request for a refill had triggered a prior authorization requirement. The doctor had to explain why this patient still deserved to be on this medication and how much it was helping to improve his condition and his life.

Dr. Resnick dutifully filled out pages of paperwork to explain to the insurance company that the patient was doing great, and their condition had really improved on the drug. Dr. Resnick was faced with a rejection stating that “the severity of the patient’s condition no longer meets criteria.” Was the doctor supposed to take the patient off the medication, let his eczema flare, and let him suffer and miss work, etc.? Several phone calls later, Dr. Resnick was able to get the rejection overturned and approved.

Something Needed to Change!

It shouldn’t take that much effort, and the prior authorization process was in dire need of change. The time and resources that could be directed toward patient care had to be diverted by the doctor, in our example, to navigating the prior authorization process. Besides that, Dr. Resnick’s opinion as a physician was being undermined. Doesn’t he know what’s best for his patient, and if so, why is approval needed for a refill that he prescribed? Why should the patient’s treatment be delayed?

As you can see, prior authorization has for a long time been making it harder for doctors to deliver quality care. Some patients, frustrated with the wait and confusing process, even end up abandoning their treatment. The wait or lack of treatment altogether can lead to serious adverse events, including hospitalization, disability, or even death.

If the doctor in the example above wasn’t so diligent about helping his patient overturn the rejection, his patient may not have had the medication they so desperately needed. Hopefully, a new rule that was recently enacted by Centers for Medicare & Medicaid Services (CMS) will help streamline the prior authorization (PA) process and ease the enormous burden on doctors and consumers.

What Is the New “Prior Authorization Final Rule” All About?

Besides alleviating the administrative burdens for doctors, the new PA final rule promises to bring significant change to a prior authorization process that results in causing patients to delay or forego necessary care due to the wait. As you can see from the example above, it’s evident that the current prior authorization process needs to be improved to ensure prompt, consistent care for Medicare patients when they need it, and hopefully this new rule will do just that.

How the Prior Authorization Final Rule Should Help Alleviate Some of the Problems

The new rule should alleviate some of the problems and frustrations associated with prior authorization. In addition, the rule helps with the following:

  • Minimizing Care Delays: The rule intends to speed up the prior authorization process by requiring that payers respond within seven days for standard requests and within 72 hours for urgent cases. These shorter response times aim to minimize sometimes dangerous delays in patient care.
  • Establishes Standards: The rule aims to establish industry-wide standards for prior authorization processes. By creating a uniform set of requirements, CMS hopes to minimize confusion and simplify the process for health care providers and patients alike.
  • Lessens Administration Burdens: By digitizing and automating the submission and retrieval of prior authorization requests and responses, CMS aims to reduce the administrative burden on health care providers.
  • Requires Reasons for Denial: Beginning in 2026, impacted payers (such as the insurance companies behind private Medicare “advantage” plans) must provide a specific reason for a denial of prior authorization decisions, regardless of the method used to send the prior authorization request. Such decisions may be communicated via portal, fax, email, mail, or phone.

The prior authorization policies described above are being finalized with a compliance date starting January 1, 2026, and the initial set of metrics must be reported by March 31, 2026. While the new final rule may not entirely eliminate all the challenges associated with prior authorization, it represents an important step towards a more efficient, streamlined, and patient-focused process.

The final rule is available to review here.

Need Help Navigating Medicare? We Can Help!

At the Farr Law Firm, we are always looking for ways to better serve our clients, and we’re excited to maintain our relationship with Retirement Together, which is focused on your Medicare health plan and drug plan needs. We work with the excellent team there because of their knowledge, experience, and dedication to client service. Learn more here.

Medicare Doesn’t Cover Nursing Homes – Now Is Also the Time to Plan for Long-Term Care

Just as it is important to keep up with all of the newly enacted rules of Medicare, it is also important to plan for long-term care. More than two-thirds of us will need some sort of long-term care in the future, but Medicare will NOT cover those costs.

Medicare Part A provides coverage for short-term stays in skilled nursing facilities but only for short-term rehabilitation. If you only require custodial care, such as help with bathing, dressing, and eating, that is considered long-term care and not health care, and it is not covered by Medicare or any other type of health insurance.

If you or a loved one is worried about long-term care, nearing the need for long-term care, or already receiving long-term care, please call us to make an appointment for your initial consultation:

Medicare Planning Fairfax: 703-691-1888
Medicare Planning Fredericksburg: 540-479-1435
Medicare Planning Rockville: 301-519-8041
Medicare Planning DC: 202-587-2797

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About Evan H Farr, CELA, CAP

Evan H. Farr is a 4-time Best-Selling author in the field of Elder Law and Estate Planning. In addition to being one of approximately 500 Certified Elder Law Attorneys in the Country, Evan is one of approximately 100 members of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys and is a Charter Member of the Academy of Special Needs Planners.

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