Health insurance prior authorization requirements: Understand changes on the horizon and how to prepare
Thirteen hours weekly. That’s the amount of time physicians spend on health insurance prior authorization requirements, according to a recent American Medical Association survey. And while some insurers have established ‘gold card’ programs designed to streamline the process, experts say these programs may not be entirely effective because terms of participation are so restrictive. For example, in Texas, only three percent of physicians qualified for the program. Ongoing state and federal changes to health insurance prior authorization requirements may ease burdens for providers, but streamlining workflows now is crucial.
Insurers pledge to simplify prior authorization
In an effort to streamline, simplify, and reduce health insurance prior authorization requirements, dozens of insurers recently pledged to:
Enhance transparency and communication on determinations
Ensure continuity of care when patients change plans
Ensure medical review of non-approved requests
Expand real-time responses
Reduce the scope of claims subject to prior authorization
Standardize electronic prior authorization
Except for medical reviews that are in effect now, most of these changes take effect on January 1, 2026. Standardization and real-time responses take effect January 1, 2027. Payers are voluntarily implementing these changes across insurance markets, including for those with commercial coverage, Medicare Advantage, and Medicaid managed care consistent with state and federal regulations for the benefit what will likely be 257 million Americans.
CMS to test a new model for simplifying Medicare prior authorization requirements
In addition, as part of an effort to target wasteful, inappropriate services in Original Medicare, CMS recently announced it would test a new model for health insurance prior authorization requirements to determine whether enhanced technologies, including artificial intelligence, can expedite the prior authorization processes for select items and services. The agency is focusing on items and services that it has identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use. These items and services include, but are not limited to:
Electrical nerve stimulator implants
Knee arthroscopy for knee osteoarthritis
Skin and tissue substitutes
The model—named Wasteful and Inappropriate Service Reduction (WISeR)—excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed.
How will it work? Providers and suppliers for people with Original Medicare in selected regions will have the choice to submit a prior authorization request for the model’s selected items and services or go through a post service/pre-payment medical review. The model launches January 1, 2026, and the model performance period ends December 31, 2031.
Other federal changes are on the way as well
Finally, a rule finalized by former president Biden mandates faster response times starting January 1, 2026 (i.e., 72 hours for expedited requests and 7 calendar days for standard requests). The rule also requires clear denial notices that give standardized reasons for denials also beginning January 1, 2026, as well as implementation of FHIR-based application programming interfaces to automate prior authorization with full rollout by January 1, 2027. These changes to health insurance prior authorization requirements cover Medicare Advantage, Medicaid, CHIP, and marketplace plans.
Providers must find ways to reduce the prior authorization burden
The implementation of these changes requires time. During this period, physicians can work to reduce prior authorization requirements to facilitate timely access to care and minimize denials. The following are several recommended strategies to combat challenging health insurance prior authorization requirements:
Collaborate with payers. Identify top services that trigger prior authorizations, and work with payers to streamline or eliminate health insurance prior authorization requirements for these services when there is a high approval rate.
Delegate to trained staff. Train non-clinical staff to monitor health insurance prior authorization requirements and handle the prior authorization process using standardized operating procedures for each payer.
Embrace electronic prior authorization. Use EHR-integrated tools to submit and track prior authorizations in real time as health insurance prior authorization requirements evolve.
Leverage clinical decision support tools. Notify physicians when a prior authorization is likely required and suggest alternative covered options, if possible. These point-of-care tools can make a big difference in navigating health insurance prior authorization requirements effectively.
Stay one step ahead of payers. Develop pre-built documentation templates that incorporate health insurance prior authorization requirements and key clinical criteria for commonly denied services.
Track data. Monitor data (e.g., prior authorization volume, turnaround time, and denial rates) and share it with payers to drive process improvement or refine health insurance prior authorization requirements.
The right technology can help
Streamlining prior authorizations is a piece of a larger puzzle to enhance medical practice performance. Technology that eliminates wasted time, boosts profitability, and enables providers to scale their business is equally important. Learn how Medusind can help in all of these areas and more.
