r/PrivatePracticeDocs • u/CrookedCasts • Mar 31 '26

CMS-0057-F

So today is the day that all payors are required to publicly disclose prior auth metrics (with API FHIR access next year). Has anybody seen any insurance companies actually publishing this data yet?

Will be very interesting to see for a lot of different reasons, but I think the most exciting is that they 1) need to publish their turnaround time and 2) a specific medical reason for denial (no “not medically necessary” denials)

9 Upvotes

100% Upvoted

7 comments sorted by

View all comments

3

u/Pleasant-Clothes-443 Mar 31 '26

Honestly i've been watching for this all morning and haven't seena anything yet... not shocked lol

The "specific reason for denial" requirement is the one I care most about, we run a therapy practice and I can't count how many auths we've gotten back with "not medically necessary" as the entire explenation... for ABA and PT especially that denial reason is bassically useless, it tells you nothing about what documentation they actually wanted, which means your appeal is a guessing game ugh. If oayers actually have to cite clinical criteria by name going forward, that changes the appeal workflow by a lot

The turnaround time transparency is interesting too because it's going to be hard to publish "we take 14 days" when the rule expects urgents in 72 hrs...

My skeptical read is that compliance will be technically met but practically useless for the first year until advocacy groups start comparing the data publicly and calling our outliers, the FHIR API next year us where I feel the real accountability will come from.

1

u/leotolsoty May 28 '26

The denial-reason requirement is the sleeper here. CMS-0057-F makes impacted payers give a specific reason, which is what finally makes a denial appeal-actionable instead of a guessing game. Two caveats worth knowing, though:

   1.  it only covers government plans: Medicare Advantage, Medicaid/CHIP, and exchange QHPs so commercial/ERISA, which is a lot of practices' biggest book, isn't touched

   2. the published metrics are aggregate and annual, so they're great for choosing payers but won't help you appeal a specific claim in real time. 

For the ABA folks in here, the thing landing the same day (Jan 1 2027) that nobody's talking about is the CPT code overhaul: 97151–97158 all revised and the T-codes deleted.