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.
Electronic Prior Authorization
Electronic prior authorization (ePA) uses integrated, FHIR-ready technology to let providers submit and receive prior-auth decisions directly through their EHR or pharmacy systems, replacing phone calls and faxes.
Gold Carding
Gold carding is a prior-authorization (PA) “fast pass” that exempts high-performing providers from most PA requirements once they demonstrate consistently guideline-adherent care.
FHIR-Based APIs
FHIR (Fast Healthcare Interoperability Resources) is positioned as the technical backbone for transforming PA from a slow, manual process into a largely automated workflow.
CMS 0057-F Webinar Recap: Here’s What You Missed
More on Prior Authorization:
Gold Card Explained: Reducing PA Burden Through Smart Provider Incentives
HHS Seeks Nominations for New Healthcare Advisory
What Is Electronic Prior Authorization (ePA) in Healthcare?
Congressional Scrutiny Intensifies Over CMS’ WISeR Model and Prior Authorization in Traditional Medicare
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white paper offers a comprehensive guide to navigating prior authorization reform, with a focus on how to modernize outdated processes, meet the 2027 commitments, and turn compliance into a competitive differentiator.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.
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.
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?
