5 strategies to expedite prior authorization for procedures as federal efforts ramp up

When it comes to relieving the administrative burden of prior authorization for procedures, several federal initiatives may pave the way. One is the Wasteful and Inappropriate Service Reduction (WISeR) model that aims to auto-approve the requests for certain services. Under the WISeR model, six states will build, test, and scale artificial intelligence prior authorization solutions that are integrated into provider workflows. However, the future of this model remains unclear. That’s because the House Appropriations Committee recently voted to pass an amendment that would block CMS from implementing it. If Congress also passes it, the amendment would remain in the final signed appropriations law, meaning CMS would not be able to use federal funds to implement WISeR in FY 2026.

Another federal initiative is a new HHS rule that accelerates electronic prior authorization for providers using ASTP/ONC certified health IT. According to the rule, certified EHRs must support electronic prior authorization by embedding the ability to assemble needed documentation and send prior authorization requests through the EHR. Certified EHRs must also allow providers to request payer coverage requirements via application programming interface.

To read the final rule in its entirety, click here. Note that while EHR vendors must begin building and certifying the required electronic prior authorization features starting October 1, 2025, full compliance isn’t required until 2028.

Similarly, payers are beginning to realize that prior authorization reform can be a competitive advantage, helping plans stay compliant, contain costs, and improve provider and patient satisfaction. Dozens of insurance companies have vowed to make fewer medical procedures subject to prior authorization and expedite the review process. Insurers also pledged to use clear language when communicating health insurance prior authorization requirements with patients and promised that medical professionals would review coverage denials related to prior authorization for procedures.

Prior authorization for procedures: Progress is underway🔗

This is all great news for medical practices. It’s also good news for patients, 73% of whom say that delays and denials of services and treatments by health insurance companies are a major problem, according to a recent poll. Almost half (47%) of those who were required to get a prior authorization in the past two years say it was ‘somewhat difficult’ (34%) or ‘very difficult’ (13%) to navigate the process of getting prior authorization for procedures.

As federal initiatives continue to evolve—and payers continue to revamp processes to promote efficiency—there are steps medical practices can take now to speed up prior authorization for procedures. Here are several strategies to consider.

1. Give payers the documentation they need up front. This may be easier said than done because every payer is different and requirements change over time. However, using payer- and procedure-specific checklists that include important details about prior authorization for procedures can help. Here’s a prior authorization checklist template that we’ve created that practices can tailor to each specific payer.
2. Designate a prior authorization specialist. This doesn’t necessarily need to be a separate full- or part-time employee, but the idea is to have someone oversee the process for prior authorization for procedures, monitor status daily, and escalate delays. This person can also stay on top of changes as payers strive to implement their pledge to simplify the process.
3. Leverage technology. Use payer portals or clearinghouses for real-time updates related to prior authorization for procedures.
4. Engage patients at the time of scheduling and throughout the process. Perform real-time insurance eligibility verification so you can let patients know at the time of scheduling when prior authorization for procedures is required and the expected turnaround time. When there are delays in obtaining the prior authorization for procedures, patients may be able to call the insurer directly to trigger faster reviews. Give patients a copy of submitted materials so they can echo the same information to the insurer.
5. Address appeals jointly with patients. Encourage patients to write personal letters to payers about the impact of delay or denial on their daily life.

Navigating prior authorization for procedures can be tricky, and there could be dire consequences when authorizations are denied or delayed. That’s why it’s so important to have the right workflows and technology in place to streamline submission, track status, and ensure compliance. Learn how Medusind can help your practice address the thorny problem of prior authorization for procedures. Visit https://www.medusind.com/ for more information.