Highlights
- Healthcare providers can submit prior authorization requests electronically, helping to streamline patient care.
- They will also have access to patients’ out-of-pocket cost details and the ability to compare drug prices before prescribing.
HHS has issued a final rule aimed at helping physicians choose the most suitable treatments while limiting insurers’ ability to deny physician-approved care, according to an agency press release.
Effective Oct. 1, the rule will enable healthcare providers using certified health IT systems to submit prior authorizations electronically, select medications aligned with a patient’s insurance coverage, and share electronic prescription data with pharmacies and payers, the release noted.
The rule will also give millions of Americans the ability to see their out-of-pocket costs, compare prescription drug prices, and review prior authorization requirements.
“This marks another step toward fulfilling our commitment to patients and providers: reducing red tape, speeding up decisions, and allowing more time for care,” said CMS Administrator Mehmet Oz, MD, MBA, in the announcement. “CMS is creating a system where choices are transparent, consistent, and centered on patients’ needs. Our goal is to make care easier, fairer, and more affordable.”
The rule follows HHS’ June announcement, when the agency and dozens of health insurers pledged six reforms to simplify and reduce prior authorization processes, aiming to ease administrative burdens.
The AMA press release highlighted that under the new rule, physicians will be able to handle prior authorization requests entirely within their electronic health record (EHR) systems. The policy “will standardize how physicians and payers share information, enabling quicker decisions and more timely patient care,” the organization said.
According to AMA, physicians will now be able to use their existing workflows to confirm payer coverage requirements, submit necessary documentation, and initiate and track prior authorization requests electronically.
“This new policy may finally signal the end of the fax era in medicine,” said AMA President Bobby Mukkamala, MD. “For too long, prior authorization has burdened staff, delayed care, and kept outdated fax machines in use because of insurer demands.”
The AMA noted that the rule integrates advanced electronic prior authorization directly into updated e-prescribing tools for medications, ensures EHRs and patient systems are interoperable, and “includes a key AMA-backed provision: real-time prescription benefit checks at the point of care. This allows physicians to see patient-specific coverage and out-of-pocket costs before prescribing — helping avoid pharmacy counter surprises and supporting more informed decisions.”
An HHS spokesperson told Healio the agency “maintains the highest standards to protect patient data.”
HHS did not address Healio’s questions about how the policies will be implemented or what providers should do to prepare. However, the AMA release said EHR vendors will be required to support the enhanced prior authorization capability. The organization also pledged to collaborate with HHS, EHR developers, and health plans to “drive timely implementation, safeguard privacy and security, and keep the focus on what matters most — delivering patient care without unnecessary delays.”
Colin Banas, MD, MSHA, chief medical officer at DrFirst, told Healio that the rule “builds on initiatives already underway.”
“It reinforces provisions introduced in the [Health Data, Technology and Interoperability Rule 2], including updates to e-prescribing standards, price transparency, and prior authorization requirements,” he said. “While not a dramatic shift, it does represent meaningful progress.”
Banas added that most physicians are already using CMS-certified EHRs, which will be subject to the new standards. “Even if providers weren’t specifically seeking these upgrades, they’ll benefit from them simply by being on a certified system,” he noted.
Banas cautioned that physicians should not expect immediate changes once the rule takes effect.
“There’s a considerable runway for many of these standards to be implemented,” he said. “For example, the price transparency requirement doesn’t take effect until 2027. So while there won’t be instant relief, within one to two years providers will start to notice improvements. By three to four years, the way we handle prior authorizations, drug comparisons, and price transparency will look very different from today’s fragmented system.”
