What people are saying about fixing prior auth—and what will actually make a difference
No healthcare stakeholder believes Prior Authorization (PA) is working well. Providers face a labyrinth of payer-specific portals, non-standard submission forms, and unpredictable turnaround times for decisions. Payers face an uphill battle to implement new APIs and reporting standards, without guarantee that providers will be ready to take advantage of them. Most importantly, patients are suffering from adjudication delays and coverage denials.
Amidst this mess, we hear every day about a new proposed “solution” that will fix PA—from the CMS-0057 Prior Authorization and Interoperability Final Rule that is right around the corner to proclamations that AI will make the whole process seamless.
Provider organizations have enough on their plate without trying to research all of the PA updates and regulations that are swirling around the industry right now. We’re here to help decode all of these proposed fixes so that provider organizations know what is signal versus noise.
What is the proposed fix? |
What will actually change? |
Valer Impact Meter |
| Major insurers announce measures to reform prior auth, including a common standard for electronic requests, fewer services that require prior auth, and more transparency about adjudication | This announcement would apply more broadly than CMS-0057-F to include employer plans—but we’re not confident that these new measures will actually account for or move the dial on the workflow challenges that make prior auth so messy. (Plus, their promises only include a streamlined experience IF “needed documentation” is submitted – which sounds like important fine print.) The devil is in the details—and the details here are still unclear. |  |
| Gold carding legislation | Gold carding initiatives are not the panacea that they seem to be. Implementation requires additional tracking and reporting that provider systems simply do not currently track, such as historical prior authorization outcomes by provider, by payer, by service; additionally, there is a lot of confusion in understanding which health plans are covered under such state-based gold carding programs (e.g. TX gold carding with little to no impact) |  |
| Turnaround Time regulation for payers in CMS-0057 |
Starting January 1, 2026, payers will have to provide PA decisions within 72 hours for expedited requests and 7 calendar days for standard requests. But given the patchwork state-by-state regulation that already exists, there’s likely to be a lot of payer confusion as to which standards apply. CMS-0057-F also only applies to Medicare Advantage, Medicaid, CHIP, and Qualified Health Plans on the Federally Facilitated Exchanges. |
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| More transparent reporting requirements for Turnaround Times in CMS-0057 |
Starting January 1, 2026, payers will have to publicly report the average TAT for PA decisions. But an average TAT report won’t provide speciality or procedure-level data—and that detail is what matters for providers who want to schedule complex, high-cost services. |
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| More transparent reporting requirements for approvals and denials in CMS-0057 |
Starting January 1, 2026, payers will have to publicly report the percentage of PA requests approved and denied—and the reasons for those denials. A standard set of denial reason codes will make PA more transparent and predictable—a good thing for providers and patients. |
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| FHIR-based APIs that payers will have to implement because of CMS-0057 |
Starting January 1, 2027, payers will have to implement APIs that:
Payers need to build out individual EMR endpoints to make the APIs workable, and as of Spring 2025, only 43% of them have started working on this. On January 1, 2027 there will likely be a mixed bag of APIs, web portals, and legacy fax workflows based on health plan/payer capabilities and service lines, possibly for a long time after the deadline. Another big consideration and challenge will be whether or not the EHR and PM providers will be equally ready handle the new FHIR API requirements, as well as the practical workflow complexities involved. |
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Heard of a prior auth fix that you don’t see here or have further questions? Submit it here and we’ll update our tracker to share what impact we believe it will have.
Ultimately, provider organizations who want a more streamlined, effective PA process shouldn’t settle for the relatively small impact of some of these regulations and technologies. Contact us today to learn more about how automation and transparent reporting can make a meaningful difference for your organization.
