Why practices and hospitals will still drown in prior authorization, even after payers pledge key reforms

This summer, dozens of health plans pledged a series of key reforms to improve prior authorization processes, which have become more and more of a flashpoint across the industry. Physicians, other clinicians and patients are fed up with health plans for denials and delays that compromise care, and health plans and policy makers have tried — often earnestly — to tame this administrative mess. Even before this latest round of pledges, health plans have scrambled to implement programs like gold carding to reduce the number of services that require approval for high-performing providers. Unfortunately, gold carding is similar to this newest wave of promised reforms: It seems like a move in the right direction, but it doesn’t address the root issues that make prior authorization such a burden for the provider staff who submit and monitor them every day.

Let’s start with what health plans are broadly pledging: Key promises include standardizing the submission process with electronic FHIR-based application programming interfaces (APIs), providing transparent guidelines about prior authorization determinations and providing real-time responses on a majority of prior authorization approvals — that is, if all of the required documentation is included.

That’s a pretty big if — and it speaks to the challenge in general with prior authorization. There are so many conditions that must be met for a prior authorization submission to go smoothly, and most of those conditions won’t change with this round of health plan pledges, or even with the CMS Interoperability and Prior Authorization Final Rule (which has some overlapping provisions with the health plan pledges).

Practices and hospitals will still face the fragmented, labyrinthine processes they always have. Here’s why.

The dynamics that keep prior authorization broken

Prior authorization has long been a costly burden for practices and hospitals: On average, one single prior authorization takes 22 minutes to complete and costs provider organizations nearly $11. Provider organizations are bearing the brunt of technology and processes that do them no favors.

First, provider organizations often don’t have the resources or time to train frontline staff or standardize their internal workflows — an understandably daunting task when submission processes are constantly changing. Patient access teams have heavy turnover, and staff members are often learning how to submit a prior authorization on their own, via trial and error. Many prior authorizations require detailed clinical documentation, and without a clinical background, staff members often resort to their best guess. The system does not set them or their managers up to succeed.

Second, they are working with outdated technology that was not designed for prior authorization workflows. A staff member may initiate the prior authorization process in the electronic health record and quickly resort to manual workarounds — as manual as a sticky note — to remind themselves of all the documentation needed or which portal or fax line they need to submit through for each insurer or procedure type. Even when government-regulated health plans start to implement electronic FHIR-based APIs (which are mandated by Jan. 1, 2027), there will be a transition period before the new workflows are universal. Health plans need to build out individual electronic medical record end points to make the APIs workable, and as of spring 2025, only 43% of health plans and 52% of providers had started to work on the API requirements. (Yes, providers also need to be able to integrate into the APIs on their side, an effort that also requires advance planning and resources.)

Third, as alluded to above, the documentation and submission process contains many trip wires that aren’t accounted for by government regulation or voluntary health plan pledges. For example, when a staff member submits a prior authorization for a procedure, they need to use the exact provider/facility combination contracted for that patient, and any error in National Provider Identifier or location can result in a costly denial. Even a small error could lead to delays that compromise patient care — a result that I’ve seen firsthand in my 13 years as a practicing pediatric surgeon.

In other words, this latest wave of reforms isn’t changing the fundamental dynamics that bog down practice and hospital staff — and make prior authorization costly, burdensome and dangerous for providers and patients. So what will?

Three fixes for our most persistent prior authorization challenges

Taking prior authorization challenges seriously means peeking underneath the hood of the entire system — and giving practices and hospitals more detailed, accessible data and better workflow solutions, including the following:

• Data-driven standards and training for workforce gaps. In helping provider organizations streamline and speed up prior authorization, I’ve seen significant variance in time spent per prior authorization submission and even approval rate per submission based on which staff member is doing the work. With little training and standardization around best practices, this isn’t surprising. Managers need to provide guidance and key performance indicators to help staff submit prior authorizations more accurately and more quickly. To accomplish this, they need solutions that track staff performance and provide actionable data about internal bottlenecks.
• A single platform to work all prior authorizations. Electronic, API-driven submissions for prior authorization sounds great — but FHIR-based APIs don’t currently account for all the nuances of coverage determinations and other bespoke prior authorization requirements, and we are a long way off from a full, seamless transition to APIs. Providers need to seek out solutions that allow them to work all of their prior authorizations out of a single platform, regardless of what specialty, service or health plan is involved.
• More detailed data about prior authorization ruling patterns. The Centers for Medicare & Medicaid Services and health plans are moving in the direction of increased transparency around turnaround time for decisions and a standard set of denial codes to help make prior authorization more predictable. However, these data will not necessarily be robust enough to help providers improve their operations. Average turnaround time, for example, is much less helpful than having turnaround time data broken out by specialty, service line and health plan, based on a provider’s actual record of submissions to that health plan. Staff would benefit more from a solution that can provide them with real-time, real-world, granular data about their prior authorization submissions.

For true reform, the devil’s in the details

At the end of the day, prior authorization will always be a process driven by people: the patients who need the care and the practices and hospitals who must navigate a near-impossible task to administrate it. Health plan pledges and policy efforts are directionally correct, but it’s time to dig deeper into the underlying workflow and data challenges that are the true culprits.

Steve Kim, MD, MBA, MSCE, is co-founder and CEO of Valer. With more than 20 years of medical experience and a passion for studying value-based care outcomes, his expertise has been vital in navigating the evolving complexities of the health care industry and identifying the administrative roadblocks and bottlenecks delaying access to care.