In the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (2020 OPPS Final Rule), the Centers for Medicare and Medicaid Services (CMS) established a prior ...

When stakeholders think about prior authorization in the Medicare program, they usually focus on its use in Medicare Advantage (MA), and not how it is used in traditional Medicare. In fact, a few ...

The Centers for Medicare and Medicaid Services (CMS) has implemented prior authorization requirements for certain traditional ...

Prior authorization is a process that involves contacting a person’s Medicare provider to request coverage for a medical service, drug, or piece of equipment. If a person has Original Medicare (parts ...

Surveyed medical groups reveal burdens have increased in the past 12 months, resulting in delays or denials for necessary care. Despite scrutiny of prior authorization practices in Medicare Advantage ...

Medicare Advantage prior authorization (PA) is the process you go through to get certain services and drugs approved before ...

Does Medicare require prior authorization? Medicare Advantage plans often require prior authorization. But these coverage reviews are rare for original Medicare. That distinction changes in 2026. Many ...

Administrative costs are estimated to make up between 20 and 34 percent of US health care expenditures, roughly 1–4 percent of GDP. Academic and policy discussions generally characterize these costs ...

Nearly all MA enrollees are subject to prior authorization — where providers have to receive an insurers’ approval before offering a service or medication — for some types of care, according to the ...

Nearly 53 million prior authorization requests were sent to insurers in 2024, compared with nearly 50 million in the prior year, according to KFF. Almost 8% of those requests were partially or fully ...