Prior Authorization

Skyrocketing prior authorization requirements have placed an acute burden on hospitals and patients alike. Today, many prior authorization transactions are still conducted through a fragmented mix of proprietary payer portals, phone calls, fax machines and manual processes. Hospitals must devote substantial staff time and resources to navigating these workflows, which can increase administrative costs, contribute to workforce burnout and delay patient care. The burden is especially pronounced for hospitals serving Medicare Advantage beneficiaries, who often face greater prior authorization requirements and related care delays. Nearly 90% of physicians report that prior authorization somewhat or significantly increases physician burnout.

Change is on the horizon. As major provisions of the 2024 Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule take effect on Jan. 1, 2027, hospitals and health systems should begin preparing for significant changes to prior authorization workflows, payer interactions and information exchange. While electronic prior authorization will not eliminate prior authorization requirements, it is expected to accelerate the exchange of information between providers and payers and reduce reliance on manual processes.

As hospitals and health systems prepare for this transition, the AHA offers resources to help navigate the road ahead.

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Blog: Electronic Prior Authorization Arrives Jan. 1, 2027:
What Hospitals Need to Know

As major provisions of the 2024 Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization final rule take effect next year, hospitals and health systems should begin preparing for changes to prior authorization workflows, payer interactions and information exchange. Read More