How CMS is Reforming Prior Authorization

Alexandra (Alix) Goss Goss and Kendra Obrist with Point-of-Care Partners highlight how CMS-0057 is driving the transformation of prior authorization (PA) through automation and interoperability. They emphasize that organizations should move beyond compliance, leveraging FHIR-based solutions and Da Vinci Project implementation guides to streamline workflows, reduce administrative burden, and improve patient care. Real-world pilots—like Washington State's FHIR PA mandate, Regence & MultiCare’s 4x faster approvals, and the Da Vinci Trebuchet pilots—demonstrate how standards-based automation enhances provider-payer collaboration. With Da Vinci’s implementation guides, organizations can shift from fragmented, proprietary systems to interoperable, scalable solutions that reduce delays and improve outcomes. The key takeaway? CMS-0057 isn’t just a regulatory requirement—it’s an opportunity to modernize PA, improve efficiency, and deliver better healthcare. https://lnkd.in/e8pcaDXu #FHIR #DaVinciProject #PriorAuthorization #Interoperability #HealthcareInnovation

Is CMS trying something the MA carriers can learn from? With all the pressure on carriers around prior-authorization, it’s clear that it does serve a purpose of reducing fraud waste and abuse as well as reducing care that doesn’t have clinical benefit. It’s become obvious that the downside impact on the member’s and provider’s felt experience has not been top of mind enough for the carriers and now they face increasing pressure to reduce it. Meanwhile, Original Medicare has many similar issues and the news about the $10+ Billion in fraud led by Russian organized crime is just the latest proof that the authorization protocols in Original Medicare are not working well enough. The absence of networks in that world makes it an even more target rich environment and the unusually high rate increases and plan pullouts in the Medsupp market are another sign of those issues playing out. CMS decided to actually do something about it, not with more government regulations, but by asking the private sector to help solve the issue and take some upside when they do. Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars. What can carriers learn from this? How can they use market forces to accomplish the same goal of cost containment for things with no clinical impact and reducing waste fraud and abuse, without degrading the ecosystem experience. It’s clear from the WISeR Model details that CMS has been learning from some MA carriers what might work, especially leveraging technology for instant decisions and they seem to be very clear that they are looking for enhanced technology solutions, and not more clunky human review. The AI revolution could not have come at a better time to deal with these issues, now it is time for the education to go the other way too and for MA carriers to learn from CMS’s new RFI. The responses are generally public, so the education will be free! They better hurry up. The debate over MA vs Original Medicare being a better financial deal for the Country will be answered in a way the MA carriers don’t like if CMS gets better at driving these outcomes (using the private sector) than the private market is able to do on it’s own.

ALERT! CMS Newsroom Immediate Release: "CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process" Key takeaway's: The Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) today. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), (collectively “impacted payers”), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Together, these policies will improve prior authorization processes and reduce burden on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years." "This final rule establishes requirements for certain payers to streamline the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule, which add continuity of care requirements and reduce disruptions for beneficiaries. Beginning primarily in 2026, impacted payers (not including QHP issuers on the FFEs) will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services. For some payers, this new timeframe for standard requests cuts current decision timeframes in half. The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics, similar to the metrics Medicare FFS already makes available." "The rule also requires impacted payers to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API), which can be used to facilitate a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process. Medicare FFS has already implemented an electronic prior authorization API, demonstrating the efficiencies other payers could realize by implementing such an API. Together, these new requirements for the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients, and prevent avoidable delays in care for patients." Link to the over 800 page final rule: https://lnkd.in/g2J7xsBr #cms #authorization #revenuecyclemanagement #frm #patientadvocate #claimsmanagement

Is this progress?! CMS has finalized payer requirements to ease prior authorization pain. What’s in this policy that will phase into effect through 2027? ✅ All payers, except for QHPs, must send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests starting in 2026. ✅ Payers must provide a specific reason for denying a prior authorization request, clearing the way for providers to appeal the decision with more specificity. ✅ Requires payers to publicly report certain prior authorization metrics. Payers must start reporting metrics by March 31, 2026. ✅ Payers are required to implement a Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Prior Authorization application programming interface (API) to facilitate electronic prior authorization processes. ✅ Payers must add prior authorization information to their Patient Access APIs, implement a Provider Access API, and establish a Payer-to-Payer API by 01/01/2027. ✅ Payers must implement a Prior Authorization API that includes a list of covered items and services, identifies documentation requirements for prior authorization approval, and supports a prior authorization request and response. These APIs must share whether the payer approves, denies the request, or needs more information. Lets hope this is some of the most meaningful legislation passed lately that actually helps healthcare providers and care delivery. #revenuecyclemanagement #healthcarefinance #priorauthorization

🚨 Major Changes Coming to Prior Authorization in 2026 🚨 CMS is rolling out the most significant Prior Authorization reforms we’ve seen in years — aiming to make the process faster, more transparent, and less burdensome for providers and patients. 🔹 Key Highlights: ✅ Faster Turnaround: Urgent requests in 72 hours, standard in 7 days ✅ Greater Transparency: Public reporting of PA volumes & decision times ✅ Tech-Driven Efficiency: Electronic PA & FHIR-based APIs for smoother data exchange ✅ Traditional Medicare Pilot: WISeR program bringing PA to 17 outpatient services in select states ✅ AI in PA Decisions: Speeding up reviews — but with licensed clinicians making final calls 💡 For providers, payers, and health tech companies — now’s the time to upgrade workflows, integrate APIs, and prepare for electronic prior auth as the standard. 📅 Effective: Most changes begin January 2026, with further standardization by 2027. #Healthcare #CMS #PriorAuthorization #Medicare #HealthTech #RCM #Interoperability #PatientCare #MedicalBilling

Authorization update, we need to press this issue: Numerous initiatives are underway in Washington D.C. in 2025 to address and reduce the burden of prior authorization in healthcare: CMS Regulations: The Centers for Medicare & Medicaid Services (CMS) finalized rules in 2024, effective in 2025, to streamline prior authorization within Medicare Advantage and Medicaid programs. These rules require faster decision times (72 hours for urgent requests and 7 calendar days for standard requests). They also promote interoperability through FHIR-based APIs and require payers to provide specific denial reasons and publicly report prior authorization metrics. Voluntary Industry Commitments: Over 40 health insurance plans have voluntarily pledged to simplify and reduce prior authorization processes. These commitments include working towards standardized electronic prior authorization and aiming for real-time approvals for most electronic requests by 2027. Insurers have also committed to specific reductions in the scope of claims requiring medical prior authorization by January 1, 2026, and honoring existing prior authorizations during plan transitions for 90 days. Legislative Action: Lawmakers reintroduced the Improving Seniors' Timely Access to Care Act in May 2025, aiming to establish an electronic prior authorization process for Medicare Advantage plans and increase transparency. This bill aligns with the AMA's principles for prior authorization reform. The Reducing Medically Unnecessary Delays in Care Act of 2025 was also reintroduced, seeking to ensure that only specialty board-certified physicians review treatment decisions in Medicare programs. Additional Initiatives: Some insurers are expanding "gold card" programs. CMS launched the WISeR Model to reduce medically unnecessary care. AI is being explored to enhance the prior authorization process through automation and streamlining. Despite these efforts, challenges remain and we must support all the specialty society PACs like those of American Society for Radiation Oncology (ASTRO) ACRO - American College of Radiation Oncology American Society of Clinical Oncology (ASCO) and American Board of Radiology ABR Radiology Business Management Association Please volunteer in society committees to reform the authorization process to improve efficiency and ensure timely patient access to care.

Understanding CMS-0057-F Compliance: A Guide for Health Plan Executives Executive Summary The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is poised to transform healthcare payer operations by mandating streamlined, interoperable processes for prior authorizations and enhanced data exchange capabilities. For health plan executives, this represents both a compliance challenge and an opportunity to improve operational efficiency, provider relationships, and patient outcomes. This guide details the key compliance requirements, phased implementation timelines, and critical strategic steps needed to achieve compliance while minimizing disruptions and maximizing value. Key Compliance Requirements Electronic Prior Authorization CMS-0057-F mandates the implementation of electronic prior authorization processes via FHIR-based APIs to reduce administrative burden. Payers must integrate these APIs with provider EHR systems to enable seamless data exchange and support automated decision-making for certain requests. To enhance efficiency and member experience, urgent prior authorization requests must be completed within 72 hours, and standard requests within seven days, setting a new industry benchmark for responsiveness. API Implementation Requirements Payers are required to deploy multiple APIs—enhanced Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs. All APIs must align with FHIR Release 4.0.1 standards, ensuring interoperability and compliance with CMS guidelines. These APIs aim to standardize data sharing across stakeholders, offering real-time, accurate information exchange and laying the groundwork for scalable, interconnected healthcare ecosystems. Data Exchange Standards Compliance extends beyond APIs to include the use of standardized FHIR resources and support for bulk data exchange capabilities. Payers must adopt APIs that integrate prior authorization requirements, documentation, and decision processes to facilitate uniform workflows. Additionally, real-time data sharing capabilities must be implemented to provide instant insights to providers, ensuring that information is accessible and actionable when needed. Implementation Timeline Phase 1: January 1, 2026 The initial phase emphasizes foundational API implementation, including the Provider Access API, enhanced Patient Access API, and Prior Authorization API. Payers are also expected to initiate the tracking of response time metrics for prior authorizations, establishing early benchmarks for performance measurement. Phase 2: January 1, 2027 The second phase requires the deployment of the Payer-to-Payer API to ensure continuity of care across plans and full integration of electronic prior authorization systems. By this deadline, all compliance requirements must be operational, with provider systems fully integrated to deliver real-time, automated workflows. Technical Requirements API Standards Continued… (link in bio)

The Centers for Medicare & Medicaid Services (#CMS) has just announced a long-awaited final rule that brings crucial reforms to prior authorization processes. This new rule slashes patient care delays and introduces electronic streamlining for physicians to obtain the necessary prior authorization to prescribe the appropriate medications and procedures that patients desperately need. The changes outlined in the rule are expected to result in significant cost savings for physician practices, estimating a whopping $15 billion over the next decade per the Department of Health and Human Services (#HHS). Streamlining the prior authorization process electronically with time limitations on urgent and non-urgent requests will reduce hospital admissions and #readmissions linked to delays in prior authorization requests for critical medications and procedures. By doing so, we're not only saving valuable time but also improving overall outcomes for patients. Imagine a #healthcare system with instant response and transparency on medication prescriptions and procedure requests that will inform the physician-patient decision-making process. #priorauthorization #clinicalinformatics #clinicalexcellence #valuebasedcare #cmsdevelopment #healthinnovation #physicianburnout Link: https://lnkd.in/g9_9qj_3