Adapting to payer changes is essential for healthcare providers to streamline the process of providing timely care to patients. In our previous article on cutting through prior authorization headaches, we addressed numerous challenges that healthcare providers face, including the administrative burden created by Medicare Advantage and other commercial plans.
With vastly different approval processes among payers, these challenges increase the time, effort, and associated costs of managing the administrative burden surrounding prior authorization services. This ultimately leads to delays in patient care and an increase in denials due to authorization rejections both on the front end and back end, which negatively impacts net revenue and the patient experience.
To ensure that patients receive the necessary exams or procedures, it is essential to work with insurance companies to establish clear and consistent guidelines for healthcare prior authorization. Providers should gather comprehensive and accurate information upfront and obtain approval from the payer to cover patient services. By establishing clear lines of communication, providers can ensure that they are providing the necessary documentation and clinical information to obtain prior authorizations. Providers can also use technology, secure messaging platforms, and automation to improve communication with payers, patients, and other healthcare providers leading to increased efficiencies and a decrease in manual errors.
Implementing a standardized prior authorization process helps healthcare providers streamline their workflow, ensure compliance with payer requirements, and improve patient outcomes. Investing in training programs helps ensure that staff have the necessary skills to navigate the prior authorization process, ideally in a centralized delivery model.
Payers frequently update their prior authorization requirements, and healthcare providers must stay up-to-date. Providers should leverage their payer relations team, subscribe to payer newsletters, attend webinars, and participate in professional organizations to stay informed on the latest requirements and processes.
Thankfully, the pendulum appears to be shifting in favor of the providers to help reduce increasingly burdensome prior authorization requirements. Looking ahead, there are significant changes to be aware of as it relates to payers and the regulatory landscape. These include:
CMS Prior Authorization Ruling
Beginning in 2026, a Centers for Medicare & Medicaid Services (CMS) ruling mandates that certain payers, including MCR Advantage, state Medicaid and CHIP agencies, will have to provide more detailed denial reasons as well as support interfaces for electronic prior authorization. These changes are intended to help streamline the process and reduce the time taken for prior authorizations and are estimated to save $15 billion over 10 years.
Specifically, the ruling details strict timelines for prior authorizations, with a 72-hour turnaround time for urgent cases and a seven-calendar day turnaround time for standard requests. This will ensure that patients receive timely care and that providers are able to make informed decisions about a patient's health without delays
Payer Prior Authorization Reductions
Recent payer updates indicate that some insurance companies are taking steps to reduce the number of prior authorizations required for medical procedures. For example, Cigna is reducing the number of prior authorizations required for 600 procedures, while UnitedHealthcare is planning to reduce the number of prior authorizations by 20% of procedures. Blue Cross is also removing prior authorization requirements for millions of members in Michigan and Massachusetts. While more is needed, these changes represent a move in the right direction for payers to standardize requirements for authorization to make the process smoother and less burdensome for healthcare providers.
Gold Card Act
The Gold Card Act is a law passed in Texas that stipulates payers waive prior authorization on services and prescription drugs ordered by providers with a history of prior authorization approvals meeting or surpassing 90% in the preceding 12 months. While there is mixed feedback on the initial enforcement of the Gold Card Act, the goal is to create a more efficient and effective streamlined process for obtaining prior authorization for healthcare providers that meet a certain threshold of services. Its success could have positive implications for providers nationwide in the future.
Intelligent Automation
Just as providers are seeking to implement intelligent automation solutions, payers are also investigating and implementing artificial intelligence (AI) to automate various aspects of prior authorization, including identifying missing information, predicting approval likelihood, and triaging cases for human review to increase speed in identifying and denying claims, potentially impacting patient care.
Healthcare providers will need to continue to adapt to payer changes to streamline the prior authorization process to improve the patient experience and ensure timely care. Our webinar Cutting Through Prior Authorization Headaches, will help you stay up-to-date with payer changes as regulations evolve to ensure your organization can master prior authorizations and thrive.
Matthew Bridge
Ryan Chapin
