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The Implication of New Changes for Prior Authorization in the U.S.

The Simplify Prior Authorization initiative and other groups and individuals have been advocating for change to the prior authorization process in Canada. As we have done this, we have also been looking to the U.S. and other countries for new developments. Change at the federal level is now coming to the U.S. What does this mean for Canada?

The U.S. Centers for Medicare and Medicaid Services, CMS, have finalized a ruling that will implement reforms including the implementation of electronic prior authorization. According to the Biden administration, the new rules will help some insurers by cutting their review process in half and will be hailed by physicians who have concerns about how the prior authorization process impacts timely access to care for patients, and their own administrative burden.

These rules are part of a larger effort in the U.S. to streamline the prior authorization process. The American Medical Association has been active in advocating for prior authorization reform through their Fix Prior Authorization campaign.

The President of the American Medical Association, Dr. Jesse M. Ehrenfeld, MD, MPH, agrees. In a recent video and podcast update released by the AMA Ehrenfeld shares how the burden on physicians will be eased and delays in care for patients will be reduced for those covered by federal government-regulated health plans – including Medicare Advantage, Medicaid, and Children’s Health Insurance Programs.

According to Ehrenfeld, as of 2026 the CMS rule is also going to require insurers to provide very specific denial reasons and public reporting of metrics around approval and denial numbers, and processing time. Sharing this information with patients will go a long way in bringing much needed transparency and accountability to the entire process. CMS will also require the shortening of time frames for prior authorization decisions to reduce care delays for patients. Payers will be required to send a prior authorization decision within 72 hours for expedited or urgent requests and seven calendar days for a standard request.

Electronic prior authorization (ePA) requirement will take effect in 2027 and integrate with physician’s electronic health records. The reforms that include ePA are expected to save U.S. physician practices $15 billion over the next decade.

There is growing awareness of the benefits of improvements in PA processes. Some provincial drug programs in Canada have already implemented changes, including electronic prior authorization. Several U.S. states have already enacted legislation mandating specific process improvements from private insurers. The SPA initiative looks forward to continuing to support improvements to the PA process in Canada that will reduce administration, improve timelines to access prescribed medications for patients, and provide better opportunities to measure health outcomes on an aggregate basis.

Simplify Prior Authorization has been analyzing new legislation in the U.S. and what we can learn from the American experience. Read our blogs on prior authorization legislation here or see our recent blogs below. 

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