What impact does prior authorization have on CMS claims processing?

Prior authorization is a requirement for certain services or treatments where healthcare providers must obtain approval from the insurer or Medicare before delivering the service. The main purpose of this process is to determine medical necessity and appropriateness before the service is rendered. One significant impact of prior authorization on CMS claims processing is that it can create delays and barriers for patients seeking access to necessary care, as providers must wait for approval before proceeding.

This waiting period can contribute to longer patient wait times, postponed treatments, and in some cases, potential negative outcomes if timely care is delayed. Additionally, when prior authorization is denied, it complicates the process further by requiring appeals and resubmissions, which can extend the timeframe before a claim is ultimately processed. Therefore, the correct answer highlights the reality that while prior authorization serves a purpose in managing costs and ensuring appropriate care, it inherently introduces complexities and delays into the claims process, affecting patient access to necessary services.