Panel Discussion: Navigating Prior Authorization Regulations

Long-standing prior authorization dysfunction – with symptoms like physician frustration, delayed patient care, staff burnout, and more – is increasingly grabbing the attention of industry professionals and policymakers alike. In response, both federal and state legislatures are taking decisive actions to correct the pitfalls of manual prior auth processes. These new prior authorization regulations however are a bit of a good news, bad news situation, as the new regulatory movement is creating simultaneous excitement and confusion in the industry. Many are left wondering: what do these new regulations actually mean for individual health systems and patients?

Our most recent webinar compiled an expert panel to analyze the ongoing and evolving nature of prior authorization regulations. Our panel featured attorney Michele Madison of Morris, Manning & Martin; revenue cycle experts Evan Martin and Tim Holland from The Wilshire Group; and physician Dr. Steve Kim from Valer.

Let’s take a look at some of the burning questions answered during the session.

What are prior authorizations, and how have they evolved?

Prior authorizations are like getting a permission slip from your health insurance company. Before you can receive certain medical treatments, tests, or medications, your healthcare provider must obtain approval from your insurance company. Initially meant to ensure treatments were medically necessary, prior auths have quickly turned into a cost-saving measure, causing care delays, extra paperwork, and significant frustration for patients and healthcare providers.

What’s the current landscape of prior authorization regulations and legislation? 

In January, CMS announced finalized rules tied to prior authorization to enhance transparency and data collection throughout the process. Since then, the topic of prior authorization legislation has gained significant traction, with payers, providers, patients, and vendors hoping to understand how these regulations will impact daily operations and patient care.

There is also regulatory movement occurring at the local level. Nine states have already enacted comprehensive legislation, and an additional 30 states are working on similar bills. Each state’s regulations vary, covering aspects such as response times and data requirements. Some states are also exploring “gold carding,” which allows providers with high approval rates to bypass prior authorizations for certain services.

How will these changes affect administrative teams and patient access?

Prior authorization regulations aim to cut down on administrative work and improve patient access to care. This means fewer headaches for administrative teams and smoother care delivery for patients. Once this legislation is in effect, the onus will then fall on individual administrative teams and physicians to track key performance indicators tied to prior authorization processes to see how these changes are playing out in real-time. This will help inform future legislation while also holding insurance companies accountable, making the appeals process smoother.

What’s missing from the current prior authorization regulations?

While these new regulations are a step in the right direction, there’s still room for improvement. Some scenarios, like changes in medical necessity during procedures, aren’t fully covered under the CMS rules or local regulations. Luckily, advocacy groups and industry leaders are pushing for more comprehensive reforms.

With efforts like the #FixPriorAuth campaign by the American Medical Association (AMA) and other advocacy initiatives, the future looks bright. Everyone in the healthcare industry is passionate about delivering the best patient care possible, and streamlining the prior authorization process is a big part of that mission. At Valer, our mission is exactly that: to streamline and simplify the prior authorization process through workflow automation for all care settings, specialties, and payers.

To learn more about prior authorization regulations and how they might impact providers, patients, and vendors once they take effect, watch our latest webinar here: Prior Authorization Regulation: Facts & Future for Patients, Providers, and Payers