How to Reduce Prior Authorization Delays

Healthcare Denials & Prior Authorization: Striking the Right Balance Rising denial rates by insurers are making headlines. Patients are left without critical care, and providers are frustrated. But here’s a balancing perspective: prior authorization—a key driver of denials—can serve a useful end if done right. Why Prior Authorization Matters: - It helps prevent fraudulent claims and unnecessary spending, ensuring resources are directed where they’re needed most. - It acts as a check against overuse of low-value care, promoting evidence-based practices. But the current system has flaws. Legitimate, evidence-based care is often delayed or denied, causing hardship for patients and providers alike. How We Can Reform Prior Authorization:  - Streamline the Process: Simplify approval pathways for treatments backed by strong evidence, reducing administrative burden for providers. - Create “Gold Card” Programs: Reward providers with a history of appropriate care decisions by granting automatic approvals for certain requests. - Enhance Transparency: Clearly outline criteria for approvals and denials, so patients and providers know what to expect. - Implement Timely Decision Standards: Set limits on how quickly insurers must respond to urgent and routine requests to minimize delays. - Leverage Technology: Use AI to flag low-risk cases for auto-approval, allowing human reviewers to focus on complex or potentially wasteful claims. The Goal: A smarter system that prevents waste and fraud without creating barriers to necessary care. Reforming prior authorization can ensure healthcare remains patient-centered while controlling costs responsibly. What changes do you think are most needed in prior authorization? #HealthcareReform #PriorAuthorization #PatientCare

I'm just floored by this #NYTimes op-doc, which so hauntingly paints the tragedy of #priorauthorization delays and denials. I've spent the last 5 years working to solve this issue using technology--and actually helped providers fully automate nearly half of the most common prior authorization requests, and even more (>80%) when payers also adopted #AI to provide point-of-care approvals. Yet #priorauthorization remains one of the most difficult and tenacious challenges for us today. The truth is that the policy solutions touched on in the video only scratch the surface of the challenges because while they nominally reduce the number of prior authorizations, they do nothing to make the system more efficient for everyone else who still needs to obtain one. What we need is widespread adoption of electronic prior authorization standards, automated prior authorization checks (again, possible with tech), and transparency for patients (not a maze of websites, call centers, and faxes). This is not rocket science. We have the technology to do this. We just need to will--or the regulatory kick in the pants--to ensure that payers and providers actually adopt it.

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

The Centers for Medicare & Medicaid Services (#CMS) has just announced a long-awaited final rule that brings crucial reforms to prior authorization processes. This new rule slashes patient care delays and introduces electronic streamlining for physicians to obtain the necessary prior authorization to prescribe the appropriate medications and procedures that patients desperately need. The changes outlined in the rule are expected to result in significant cost savings for physician practices, estimating a whopping $15 billion over the next decade per the Department of Health and Human Services (#HHS). Streamlining the prior authorization process electronically with time limitations on urgent and non-urgent requests will reduce hospital admissions and #readmissions linked to delays in prior authorization requests for critical medications and procedures. By doing so, we're not only saving valuable time but also improving overall outcomes for patients. Imagine a #healthcare system with instant response and transparency on medication prescriptions and procedure requests that will inform the physician-patient decision-making process. #priorauthorization #clinicalinformatics #clinicalexcellence #valuebasedcare #cmsdevelopment #healthinnovation #physicianburnout Link: https://lnkd.in/g9_9qj_3

AI Agents Are Transforming Healthcare – Here’s Proof Imagine a healthcare system where scheduling is seamless, patient intake is effortless, and administrative bottlenecks no longer slow things down. Where prior authorizations, referrals, and follow-ups happen in real-time—without delays. This is the power of AI agents in healthcare. These intelligent assistants automate time-consuming tasks, streamline operations, and improve efficiency at every level. One company leading this shift is Innovaccer, with its newly launched Agents of Care—a suite of 8 AI agents designed to optimize workflows and enhance care delivery. Here’s what they do: 🔹 Scheduling Agent – Automates appointment booking, provider matching, and reminders to reduce no-shows and optimize schedules. 🔹 Protocol Intake Agent – Collects patient information, verifies insurance, and updates records, making the intake process faster and smoother. 🔹 Referral Agent – Manages referrals end-to-end, ensuring timely specialist appointments while minimizing network leakage. 🔹 Authorization Agent – Expedites prior authorizations by automating submissions, tracking approvals, and assisting with appeals when necessary. 🔹 TCM Agent – Streamlines post-discharge follow-ups, coordinating care to reduce readmissions and improve recovery outcomes. 🔹 Care Gap Closure Agent – Identifies and engages patients with overdue care needs, scheduling appointments and ensuring compliance. 🔹 HCC Coding Agent – Improves risk coding accuracy by identifying high-value cases, extracting codes, and validating documentation. 🔹 FAQ Agent – Provides instant, AI-powered responses to patient questions 24/7, improving access to information. The impact is clear: ✅ Faster processes ✅ Reduced administrative burden ✅ More efficient healthcare operations ✅ Better patient experiences AI agents aren’t just improving healthcare workflows—they’re reshaping the future of the enterprise. As these innovations continue to evolve, organizations that embrace AI agents will set the standard for efficiency, quality, and growth. The next era of healthcare is here. Are you ready to take advantage of it?

ALERT! CMS Newsroom Immediate Release: "CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process" Key takeaway's: The Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) today. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), (collectively “impacted payers”), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Together, these policies will improve prior authorization processes and reduce burden on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years." "This final rule establishes requirements for certain payers to streamline the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule, which add continuity of care requirements and reduce disruptions for beneficiaries. Beginning primarily in 2026, impacted payers (not including QHP issuers on the FFEs) will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services. For some payers, this new timeframe for standard requests cuts current decision timeframes in half. The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics, similar to the metrics Medicare FFS already makes available." "The rule also requires impacted payers to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API), which can be used to facilitate a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process. Medicare FFS has already implemented an electronic prior authorization API, demonstrating the efficiencies other payers could realize by implementing such an API. Together, these new requirements for the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients, and prevent avoidable delays in care for patients." Link to the over 800 page final rule: https://lnkd.in/g2J7xsBr #cms #authorization #revenuecyclemanagement #frm #patientadvocate #claimsmanagement