Legislative Changes Impacting Prior Authorization

From Scalpel to Senate: Cutting Through the Red Tape ✂️🦴🇺🇸 This week, I had the privilege of traveling to Washington, D.C. to meet with U.S. Senators and Representatives on behalf of Resurgens Orthopaedics and United Musculoskeletal Partners to discuss a critical issue affecting patients and providers alike: prior authorization reform. As a practicing orthopedic surgeon, I’ve seen the toll that unnecessary administrative delays take—especially on seniors who can’t afford to wait weeks or months for medically necessary care. The conversations on the Hill centered around two key legislative efforts: 📜 The Improving Seniors’ Timely Access to Care Act – • Senate Bill S.4532 and House Bill H.R.8702 both aim to modernize and streamline the prior authorization process within Medicare Advantage by requiring real-time electronic prior auth, increased transparency, and CMS oversight. • An earlier version, S.1816 / H.R.3515, has also gained significant bipartisan support and focuses on standardizing decision timelines, increasing accountability from insurers, and reducing care delays. 💻 CMS Final Rule CMS-0057-F – Released earlier this year, this regulation requires insurers to implement Fast Healthcare Interoperability Resources (FHIR®)–based APIs and mandates standardized prior authorization timelines: • 72 hours for expedited requests • 7 calendar days for standard requests • Effective January 2026, with full compliance expected by 2027 It also introduces a requirement for payers to publicly report prior authorization metrics and provide detailed denial justifications—pushing the system toward greater fairness and transparency. 📢 Industry Pledge Announcement – June 2025 Earlier this week, CMS and HHS announced that major insurers—covering over 275 million Americans—have pledged to voluntarily reduce or eliminate prior authorization requirements for many services. They’ve also committed to honoring prior approvals across plans and launching dashboards to increase public transparency. While voluntary, this pledge is a promising sign that pressure from physicians, legislators, and patients is creating real movement. We are on the edge of long-overdue change. Prior authorization should never be a barrier to timely, evidence-based care. I’ll continue showing up—not just in the OR, but in the rooms where policy gets made—because healthcare shouldn’t depend on how well you navigate red tape. It should depend on what your doctor determines is necessary. #PriorAuthorizationReform #HealthcarePolicy #SeniorsDeserveBetter #PhysicianAdvocacy #CMS0057 #SurgeonsWhoAdvocate #Orthopedics #DCinADay #HealthEquity

Prior auth is about to change dramatically, and adapting will cost health insurers $16.2B. Yesterday, we explored the history of prior auth and how we ended up with the frustrating system we have today. Now, let's look at the imminent regulatory changes. Here's what you need to know and how you can brace for impact: → There’s broad bi-partisan support for radically restricting insurers’ ability to conduct prior auths 1. The House of Representatives has passed bipartisan legislation demanding sweeping prior authorization reform. [1] 2. Texas, Michigan, and Louisiana have already enacted similar laws. 3. 30 more states are in the process of drafting their own legislation. → The financial impact The Congressional Budget Office estimates that complying with these new laws will cost insurers $16.2 billion. Insurers will be required to: 1. Universally adopt electronic prior authorization (ePA) 2. Maintain 24-hour response times 3. Publicly release data on all prior authorization metrics 4. Implement gold carding programs for certain providers 5. And a slew of other restrictions The industry response? Major insurers like UnitedHealthcare, Aetna, and Cigna are already preparing. They're proactively slashing their prior authorization requirements and racing to implement universal electronic prior authorization. 𝗧𝗵𝗲 $𝟭𝟲𝗕 𝗾𝘂𝗲𝘀𝘁𝗶𝗼𝗻: 𝗛𝗼𝘄 𝗰𝗮𝗻 𝗶𝗻𝘀𝘂𝗿𝗮𝗻𝗰𝗲 𝗰𝗼𝗺𝗽𝗮𝗻𝗶𝗲𝘀 𝗽𝗿𝗲𝗽𝗮𝗿𝗲? It’s going to cost a lot. There’s no getting around it. But by centralizing your prior authorization data, you can avoid the worst of it. Here's why: - Public data releases require a centralized repository of all your prior auth metrics. - Universal ePA adoption needs a centralized system to manage incoming requests. - Gold card programs require centralized tracking of provider performance. - Ensuring 24-hour response times necessitates centralized monitoring. Once you centralize your data, you unlock a world of possibilities. The big one? Automation. McKinsey estimates that with today's technology, 75% of prior auth can be automated. [2] Here’s what this will unlock for insurers facing these new laws: → Responses in minutes, not days → Public data releases with a click of a button → Gold Card programs that run themselves → Vast majority of auth requests handled without human intervention The pendulum is swinging back towards providers, but payers can adapt and thrive with the right approach. By centralizing data and embracing automation, you can slash costs, ensure compliance, and emerge stronger.

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

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.