CMS’ New Prior Authorization Rules: Impact on Medicare Advantage and Part D

CMS' New Prior Authorization Rules
The Medicare Advantage and Part D rule was implemented on January 1 by CMS.

Despite the fact that the Medicare Advantage and Part D rule which came into effect on January 1, 2019 is now in effect, it is quite early to tell whether 2024 will be the year when providers finally overcome the challenges associated with CMS’ New Prior Authorization Rules.

Currently, Medicare Advantage plans are required by CMS to review their CMS’ New prior authorization policies  on an annual basis, and these policies should remain in place as long as the patients need the services.

It is still a challenge for revenue cycle leaders in managing the prior authorization and denials, especially given the fact that the overwhelming majority of Medicare Advantage enrollees are covered under plans that require prior authorization in order to receive treatment.

In the event that organizations are not successful in resolving their prior authorization issues by investing in new technology, they may at the end of the day find themselves facing more issues in the future if they are not prepared to implement a solid digital expansion strategy in the future if they are not ready to resolve their prior authorization issues through technology.

Medicare Advantage is one of the most frustrating programs for providers due to the low reimbursement rates and frequent claim denials. Prior authorization is just the tip of the iceberg when it comes to Medicare Advantage.

Several health systems have ended their contracts with Medicare Advantage plans since they have realized that they will not be able to sustain going back and forth between Medicare Advantage plans and traditional insurance plans for a long time to come.

The president and CEO of Healthcare Industry claims that a program that was meant to provide seamless, high quality care has actually turned into a patchwork of rejections, delays, and frustrations instead of providing seamless, high quality care. In the year 2023, the health system terminated. Medicare Advantage contracts with the health system.


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