- January 17, 2025
- Posted by: Josh Knoll
- Category: Prior Authorization
Prior authorization is a well-known headache for healthcare professionals and patients. What started as a utilization management program, has eventually become an inevitable burden over the years for both providers and patients. While providers are already struggling with preauthorization requirements, the updated regulations regarding the same are going to complicate the scenario more.
In this blog, we have discussed the upcoming prior authorization changes and their impact on providers and patients.
Final 2025 MA Rule: More Prior Authorization Scrutiny?
In a continuous reexamination of Prior authorization policies, the U.S. Center for Medicare and Medicaid Services will require Medicare Advantage or MA plans to analyze the impact of pre-authorization on both providers and patients.
Expanding on the 2024 rule, the new provisions of the final “Medicare Advantage rules”[1] of 2025 require Medicare Advantage plans to establish utilization management committees to review prior authorization policies. Technically, the bill is effective from June 3rd, 2024, but it applies to coverage starting on January 1, 2025.
As of January 1, 2025, accelerated turnaround times for preauthorization processes take effect under updates made to “New Jersey’s prior authorization law”[2] by P.L. 2023, c. 296. According to this rule, non-urgent requests must be addressed and reverted within 9 days. To meet any additional requirements for approval, the providers should respond within three days.
The bill for prior authorization services in New Jersy, entitled “New Jersey Respect for Physicians Act”[3], amends the “Health Claims Authorization, Processing, and Payment Act” to require health insurance carriers to contact the providers within four hours to discuss a decision to authorize certain healthcare services and reduce the amount of time within which a carrier must respond to the Prior authorization requests.
The purpose of the rules is to ensure accessibility to necessary care without experiencing unexpected delays. Key aspects of the rule include:
- Simplification of prior authorization
- Assured care continuum
- Alignment with Medicare coverage
- Improved transparency
These changes also aim to reduce the administrative burden on healthcare providers.
So, it seems, the changes will eventually contribute to a faster Prior authorization process and enhanced care accessibility. But is it true?
Impact of Policy Change on Prior Authorization
The 2025 Medicare Advantage rule will have a significant impact on providers. Here is a simplified breakdown:
Positive Impacts
- Reduced administrative burden: Providers will spend less time on the Prior authorization process for ongoing care plans, as they will be viable for a longer period. This means less paperwork and you can focus more on patient care.
- Improved access to medically necessary services: The alignment of requirements of Medicare Advantage plans and traditional Medicare coverage can ensure providers like you can deliver quality care with fewer hurdles, while patients have access to the same benefits.
Negative Impacts
- Reduced adjustment periods: Providers like you will have less time to obtain the approvals. At the same time adapting to new policies, workflows, and timeframes will be tough for you.
- Strict oversight: With increased accountability, scrutiny will be increased considering regulatory compliance. Understanding and implementing complex legal requirements within the Prior authorization process is difficult with increasing patient volume and workload.
- Plan-specific variations: Numerous rules of various payers across the industry are a major hurdle for revenue cycle management. At a given period, you must deal with different patients with different insurers whose claim submission and preauthorization requirements are variable. For instance, a prior authorization reform bill in New Jersey brought numerous changes within the administrative process. These unique nuances demand you stay informed about numerous payer policies.
While it can reduce administrative burden and enhance care accessibility, is it feasible for you to manage this on your own?
The Bottleneck
To ensure a smooth prior authorization process, you must ensure regulatory compliance. This requires a clear understanding of the payer policies and extensive experience within the same. While you are burdened with increased patient volume, the competitive market, skill shortages, and stratospheric wages together are making it more difficult for you to sustain the functionality of your practice. Skill shortages remain a consistent problem within the industry, and transformation within authorization policies is putting more pressure on existing staff.
Get Rid of Prior Authorization Issues with Sun Knowledge
You can resolve Prior authorization issues even in this transformative environment with a team of revenue cycle management experts. Sun Knowledge Inc. has been serving some of the biggest providers within the country for more than a decade with immense expertise and experience. You can have a dedicated team of prior authorization experts in New Jersey, who can transform your practice’s workflow and efficiency. From verification to follow-up on Prior authorization requests, we can handle your entire process. While we provide tailored services according to your needs, we also offer you end-to-end RCM support.
Want to learn more about our services? Contact us at (646) 661-7853 today! Our experts would love to share insights into current industry practices and your requirements over a non-commitment call.
Ref Link:
[1] https://www.apta.org/news/2024/05/08/2025-ma-final-rule-prior-auth
[2] https://legiscan.com/NJ/text/S530/id/2873897#:~:text=This%20bill%2C%20entitled%20the%20%22New,to%20reduce%20the%20amount%20of
[3] https://www.horizonblue.com/providers/news/news-legal-notices/amendments-existing-prior-authorization-turnaround-times