Industry Report
Prior Authorization Reform
Prior authorization has long been a source of frustration across the healthcare landscape. As regulatory pressure from CMS and other industry forces grows, payers are taking action to align with new standards and expectations.
This page provides an overview of the current state of prior authorization reform, a downloadable whitepaper providing readiness tips and dynamic links to additional articles & information as it is collected.
Table of Contents
The 2027 Commitments
What does Prior Authorization Reform Mean for Payers?
Backed by CMS, AHIP, and major health plans, the 2027 voluntary commitments outline a clear path toward a more efficient, transparent, and digital prior authorization system.
Key changes include:
● Implementing FHIR-based electronic prior authorization (ePA)
● Reducing PA turnaround times, especially for urgent cases
● Providing real-time status updates and clinical justifications
● Reducing unnecessary PAs through gold carding
● Standardizing data exchange between payers and providers
While technically voluntary, these commitments reflect the industry’s future. It’s suggested that payers that move early will not only stay compliant but will also deliver faster, more provider-friendly care. There are opportunities and challenges ahead.
Opportunities
Reform isn’t just a regulatory box to check; it’s a chance to lead. Forward-thinking payers are aligning with the coming changes to:
- ● Build stronger relationships with providers through streamlined workflows and clear communication
- ● Improve member outcomes by minimizing care delays
- ● Increase internal efficiency and reduce administrative burden
- ● Strengthen their market reputation and positioning in competitive RFPs
- ● Align with value-based care models by ensuring PA doesn’t obstruct high-quality care
Challenges
Despite rising awareness of the need for reform, many payer organizations are still facing challenges. The white paper dives deep into these readiness gaps, including:
- ● Continued reliance on manual workflows, fax, and phone
- ● Data silos between UM systems, EHRs, and claims platforms
- ● Limited investment in AI and automation
- ● Poor provider communication due to unclear or inconsistent guidelines
- ● Lack of centralized PA governance or strategic leadership
Frequently Asked Questions
What makes the 2027 voluntary commitments different from past reform efforts?
Unlike previous reform initiatives, the 2027 commitments have strong alignment between CMS, AHIP, and leading health plans, and they’re supported by emerging federal rulemaking. These commitments signal a permanent shift toward automation, transparency, and interoperability in prior authorization.
How should payers prioritize their readiness efforts?
The most immediate priorities include replacing manual workflows with electronic prior authorization (ePA), implementing FHIR-based APIs for interoperability, and developing clear, accessible PA criteria for providers. Establishing internal governance and tracking key performance metrics are also essential.
What’s the risk of waiting to modernize PA processes?
Organizations that delay modernization risk noncompliance, increased provider abrasion, and reputational damage. In a competitive landscape shaped by value-based care and performance-driven contracts, falling behind on PA reform can directly impact growth and partnership opportunities.
More on Prior Authorization:
CMS 0057-F Webinar Recap: Here’s What You Missed
Congressional Scrutiny Intensifies Over CMS’ WISeR Model and Prior Authorization in Traditional Medicare
FHIR and the Future: Why Interoperability is the Key to PA Reform
Voluntary Prior Authorization Reform Initiative
Is Your Organization Ready?
This white paper offers a comprehensive guide to navigating prior authorization reform, with a focus on how to modernize outdated processes, meet the 2027 commitments, and turn compliance into a competitive differentiator.
Key Highlights
● Understand what the 2027 prior authorization reform commitments mean for payers.
● Identify the most common operational gaps and technology challenges slowing down progress.
● Explore how leading organizations are turning compliance into a competitive edge.
Partner with BHM Healthcare Solutions
With over 20 years in the industry, BHM Healthcare Solutions is committed to providing consulting and review services that help streamline clinical, financial, and operational processes to improve care delivery and organizational performance.
We bring the expertise, strategy, and capacity that healthcare organizations need to navigate today’s challenges – so they can focus on helping others.
Are you ready to make the shift to a more effective process?
