AMA's Take on CMS Prior Authorization: What's New? (2026)

The American Medical Association (AMA) has expressed its appreciation for the U.S. Centers for Medicare and Medicaid Services' (CMS) recent guidance on prior authorization reporting. This guidance, which strengthens federal transparency requirements, is a significant step forward in ensuring that patients and physicians have access to accurate, accessible, and understandable information about prior authorization processes. However, the AMA also highlights several areas where further improvements can be made.

Transparency and Accessibility

The updated guidance from CMS is a response to the AMA's concerns and recommendations, which were based on a review of 15 Medicare Advantage contracts. One of the key points of contention was the requirement for payers to publicly post prior authorization requirements and outcomes, with specific deadlines for urgent and standard requests. The AMA's analysis revealed that some payers were not meeting these transparency standards, particularly by using password-protected portals or other non-publicly accessible methods.

The new guidance clarifies that posting required metrics through such restricted portals does not satisfy the 'publicly accessible' requirement. This is a crucial improvement, as it ensures that prior authorization information is not only available but also easily accessible to the public. Additionally, CMS now specifies that plans must publicly identify all medical items and services requiring prior authorization, including the omission of entire categories of care from disclosures.

Accuracy and Usability

AMA President Willie Underwood III, M.D., emphasizes the importance of making prior authorization information 'more transparent and usable.' While the updated guidance is a positive step, Underwood points out that the work is not yet complete. He stresses the need for accurate, accessible, and understandable information that is comparable across health plans. This is a critical aspect, as it ensures that patients and physicians can make informed decisions and understand the insurance coverage they have.

Ongoing Challenges and Recommendations

The AMA has identified several remaining gaps in the transparency framework that require attention. These include:

• Defining Prior Authorization Broadly: The organization suggests that the definition should be expanded to capture 'rebranded practices' to ensure comprehensive coverage.
• Making Information Available at Enrollment: Prior authorization information should be accessible at the point of enrollment, allowing individuals to understand their coverage before making healthcare decisions.
• Standardizing Prior Authorization Reporting: Standardization is essential to ensure consistency and comparability across different health plans.

In conclusion, while the CMS guidance is a significant improvement, the AMA's ongoing efforts to address these gaps are essential to achieving a truly transparent and user-friendly prior authorization process. This is a complex issue, and the AMA's advocacy for patients and physicians is crucial in driving the necessary changes.