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February 8, 2023

Uniting in Support of Regulatory Changes to Prior Authorization

While we have big legislative priorities when it comes to workforce development, Certificate of Need reform and behavioral health, SCHA also spends a lot of its advocacy time on regulatory changes that can make a substantial impact on our member’s bottom lines. A prime example has recently come to the fore, as CMS has proposed a new rule that can make real headway on payment delays from commercial insurers.

To briefly explain–many commercial third-party payers often require prior authorization (and the denial of these requests) to do things like see specialists, get out-of-network care, or get non-emergent hospital care. In April 2022, the Office of the Inspector General (OIG) issued a report about how many of these payers used prior authorization to deny claims that met Medicare coverage rules by applying extraneous clinical criteria, unnecessary documentation, and by making manual and system errors.

In response, CMS has issued a proposed rule (CMS-4201-P) that would strengthen beneficiary protections and promote equity for beneficiaries with Medicare Advantage and Medicare Part D, a major win for hospitals after decades of pursuing relief. This rule has not yet been finalized by CMS though–hospitals across the country need to show strong support by submitting comments in favor of the Proposed Rule. In this case, the number of comments submitted is as important as the content, so SCHA is encouraging its members and partners to submit as many letters as possible.

If you would like SCHA’s support in this matter, our advocacy and regulatory teams have created a condensed version of SCHA’s own comment letter for hospital administrators to use, as well as short comment templates that can easily be used by hospital staff and physicians. Please contact Barney Osborne at if you are a member and need access to these documents or need any other help preparing your comments. Comments are due to CMS by the close of business on February 13, 2023.