The best prior authorization is the one you never had to do, says DrFirst's Colin Banas

One in four. That is the share of physicians who told the American Medical Association that medical necessity denials are consistently reviewed by an appropriately qualified clinician, a year after insurers promised exactly that.

Colin Banas, M.D., M.H.A., chief medical officer of DrFirst and former chief medical information officer at VCU Health System, walked Physicians Practice through the June 2025 pledge commitment by commitment, then looked ahead to the federal deadline arriving Jan. 1, 2027. The conversation has been edited for length and clarity.

More than 60 insurers signed that pledge, committing to six changes: qualified clinical review of denials, fewer services subject to prior authorization, continuity of approvals when patients change plans, plainer denial explanations, standardized electronic submission and real time approval of 80 percent of electronic requests. AHIP said in April that participating plans had eliminated 6.5 million prior authorizations, an 11 percent reduction across the markets covered.

The requirements with actual teeth arrive next, when affected payers have to stand up a set of standards-based application programming interfaces. Here is what Banas expects those to change, where he thinks the deadline breaks down and what he would put on a practice manager's list this month. For the reporting behind this conversation, see what practices need before Jan. 1, 2027.

A year ago you were skeptical that a voluntary pledge would fix prior authorization. Were you right?

Colin Banas: I hate to say I told you so, but I feel a little bit vindicated. Let's just say that. I was very dubious back in June of 2025 when this coalition of insurers got together and said, "We're going to make prior authorization better, and here are six things we're going to do." It felt very much like a rerun of prior pinky promises. The most recent was back in 2018, almost the same kind of pledge.

The reason I feel a little vindicated is that I am a big cinephile, so I love movies, and there was a movie and a comic book many years ago called Watchmen, and the tagline was, "Who watches the watchmen?" When I think about the pinky swear we're going to talk about here, a lot of the results are coming from the people who made the pinky swear themselves. There is no external validation. If anything, the external validation would come in the form of what my peers are seeing on the front lines.

What did insurers actually promise?

Banas: There were basically six pillars of the pinky swear. The first was that when you submit an appeal, we're going to have somebody who is qualified in your specialty actually doing the review, because a lot of the complaints were that the person looking at my request for a very specific kind of breast surgery has no idea what breast surgery involves and who qualifies for these complex procedures.

The second was to reduce the scope of claims subject to prior authorization, and that was probably the biggest part of it. One of the insurance companies said they were going to reduce prior authorizations by 20 percent, maybe even 30 percent. The third was that if you have been previously approved for a prior authorization, we're going to honor it for 90 more days if the plan switches. The fourth, again not very high on specifics, was that if it is denied, we're going to give you very clear language as to why. The fifth was standardizing the electronic prior authorization using the FHIR APIs, which is good, and which was also something already in motion by mandate. And the last one was that 80 percent of electronic prior authorizations, if they are approved, will be approved in real time.

Which of those six have they delivered?

Banas: A lot of the data I was able to dig up is self-reported. If I am looking for the sentiment from my frontline colleagues, I have to go to things like AMA annual surveys or AHA surveys to figure out what my peers are seeing. On the first one, that someone in my specialty is going to be reviewing this appeal, the survey said only 24 percent of providers were actually seeing that in practice. Three out of every four docs are saying that still isn't happening.

The second pillar, reduce the scope of claims subject to prior authorization. All we have is folks like Blue Cross Blue Shield saying, from last year we have reduced prior authorizations by 11 percent. I don't know about that. If anything, if I ask my colleagues, they think the number of prior authorizations is still going up, the amount of time spent on them is going up, and the denials, if anything, are going up. That is their data saying, hey, we cut it.

Honor existing prior authorizations when switching plans: I couldn't find anything. I don't know if that is really happening. That is almost something I would have to ask not only my provider colleagues but also the patients out there. What are you seeing when your biologic flips plans at the beginning of the new year? My guess is that it is not being honored and they are still jumping through a lot of hoops. The real problem with all of this is that not only is this how providers get frustrated and burnt out, this is how patients get hurt. I have real world stories about personal friends going through this process who ended up legitimately getting hurt.

Clear, plain language denial explanations: I don't know. You are going to have to find an independent auditor to figure that out.

Standardized electronic prior authorization: for a health IT company in medication management like DrFirst, this is the big one. This is the one that actually lays the pipes for some of the other metrics and the ability to measure this stuff, when we start the process flowing through FHIR-based APIs. There are a few out there, not very many. The mandate doesn't require them for the medical, claim-based side until the end of this year, so that is about five months away. The one for prescriptions, which is what I am really looking forward to, doesn't kick in until Jan. 1, 2027. That doesn't mean they can't be doing this ahead of time, and a very few number are, but to make a pinky swear saying we are going to do this when in the background you are being forced to do this, at least in the CMS payer community, feels a little disingenuous. It feels like taking credit for something you were going to have to do anyway.

And then 80 percent of electronic approvals in real time. I haven't seen any measurements on that. I certainly know that when I am prescribing, I am not seeing that in the slightest. I am not here to beat up on the PBM and payer community, but let's just say I do feel a little bit vindicated about the efficacy of a pinky swear.

What are physicians telling you about how the process feels today?

Banas: It is as bad as ever. I hate to be a negative Nancy on this stuff, but look at any metric about the things physicians are complaining about. Prior authorization friction is actually overtaking EHR friction. EHRs are almost no longer the number one bad guy. There are a variety of reasons why EHRs were getting a lot of bad press, and I think they were an easy target, but with the advent of AI and some of the tools that are reducing the burden of interacting with the screen and refocusing on the patient, you are seeing an even bigger swing toward taking aim at the prior authorization process and the friction created by it. Physicians are most likely to cite that as one of the causes of burnout.

I don't think in a meaningful way they are seeing anything different from June of 2025. Some very progressive health IT companies who have been fortunate to work with very progressive segments of the payer community have chipped away at specific use cases. The easiest one that comes to mind is the success we have had, and others have had, in the GLP-1 prescribing experience. We have been able to do very dedicated things that have led to almost avoiding the prior authorization altogether in real time, because you were able to satisfy a whole bunch of things in the background in nanoseconds. But that is not scaled. That is not extensible to the entirety of the prior authorization process.

So I still see frustration. I still see rooms with fax machines, which is unbelievable, and dedicated clinical teams with multiple browsers open because they are interacting with different portals for different payers and different drugs. It is all very much spaghetti. It is a non-unified experience, and it is wasteful.

What has to be built by Jan. 1, 2027?

Banas: The one I was referring to is the medical benefit prior authorization, so think of scans or surgeries, procedures or infusions. Some medication therapy is obviously on your medical benefit, and a lot of those biologic infusions are on there. But the thing I am more focused on is the one that is a year from now, which is full prescription benefit automation, or at least digitization.

In the next six months, from an electronic standpoint, they need to build four different APIs that all of the players in the ecosystem should have access to. There is a provider to payer API, meaning I need a way to go get that question set, understand the rules of this prior authorization and submit. There is a payer to payer API, meaning I switched from payer A to payer B, and payer B needs to understand the legacy of your prescriptions and the approvals. Let's make that easier. There is a patient to provider to payer API, which is, hey insurance company, what do you have on me, or let me interact with the rules of the game so that from a patient perspective I can be more informed. And the fourth is almost folded into the provider to payer one, which is the prior authorization itself. Not only am I interacting with the payer community to get data on what you have for my patient, because you might have additional data that I don't have, but I also need to be able to do those FHIR endpoints for the full prior authorization.

What should a prior authorization look like once those APIs are live?

Banas: There is an alarming number of times the patient shows up to the pharmacy counter only to find out that a prior authorization is required and that a message has been sent back to the doctor to initiate the process. That is called a retrospective prior authorization, and it is almost insanity to me. We can't figure this stuff out in the year 2026, with all of the strides we have made in health technology?

If I had to pick one word for what it looks like, it is fully transparent. That is what I want the process to be. That is what the patient deserves the process to be, so the provider knows at that moment if there are going to be additional steps on their end, or the provider knows they have avoided the prior authorization because the system took care of it in the background. Many of my colleagues and I share the same motto: the best prior authorization is the one I never had to do.

That is what I want to get to. Let's limit prior authorizations to when they really do need to be reviewed and there really is clinical evidence for why this might not be the appropriate next step, because right now more than 80 percent of all prior authorizations that are appealed are reversed. That is insane. That is almost a way of doing business, to make the money on the arbitrage of having that delay. If you are going to eventually allow 80 percent of the things you initially denied, that just doesn't make a lot of sense to me, especially when patient outcomes are at stake. Just like on your app you can see where your pizza status is, I want the patients and the providers to have that as well, and that is what this framework will eventually lead us to, hopefully.

Where is the deadline most likely to break down?

Banas: If I had to guess, it would be on the payer or maybe even the vendor side. Are you going to be compliant by these deadlines? I know at DrFirst we are fully prepared already to be participating in these new FHIR-based APIs and piping, but if we don't have somebody to connect to on the payer side, it is all for naught, and it is going to break down back to the current process, which is a lot of phone calls and faxes.

The other thing, as a subset of that, is enforcement. So you weren't compliant by the dedicated time. What happens? How do we shame you publicly, or how do we hit you from a certification standpoint, or financially? You saw this play out until recently in information blocking, where there were real examples that were getting reported and getting investigated, and nothing was happening. Now there is actually a little monetary punch, but for at least two plus years of the initial information blocking rule, nothing was really happening to the bad guys. I hope we don't make that same mistake here, because what is so great about what is happening now is that this intense focus and light is being shed on the problem, and we are finally going to get somewhere with it.

If all of it gets built and the delays remain, what does that tell us?

Banas: That the incentives are perverse. That all of this friction really was by design, which I really don't want to be true. But it tells us that we have got to relook at how this whole thing is being incentivized. If you digitize it all and the process is still broken, then the process was the problem all along. I will just leave it at that.

What has genuinely gotten better in the past year?

Banas: Because of that intense focus, and that is the frustration not only from the provider side, the patients are getting involved now too. You are seeing activated patients making a lot of noise on social media or with their local legislation, saying this is not right, this needs to be addressed. With that focus and that pressure comes progress. There are some edge cases that are already opening up that are very successful.

There are some payers who have promoted their gold card program. Gold carding is, if a doctor submits 10 prior authorizations for this infusion and they are always approved, because that doctor knows what he is doing and has already followed the evidence, then let's stop having him do prior authorizations. It is a way of saying you have earned our trust, therefore we are going to stop the friction. I have seen some progress in those.

The other thing is that with the advent of AI and large language models, you are seeing a lot of things that have lent themselves to automation start to trickle in, and prior authorization is one of those use cases that really does lend itself to it. We might not be able to get 100 percent of the prior authorization done via automation, but we can get 80, and if I can take 80 percent of the work off your plate through a DrFirst solution or an AI solution and leave the 20 percent to something that really clinically needs an extra set of eyes, that is still meaningful progress. Those are the things I am very excited for, and I think it is all because of that intense focus and scrutiny that this whole process has finally been put under.

What is one thing a practice manager can do this month to be ready for 2027?

Banas: I would definitely check in with your EHR or your prescriber vendor and figure out where they are in terms of compliance, or expected compliance. Not only is this coming up, but there are other really important things like NCPDP standards that are right afterwards, so you really need to be on top of them to make sure they are indeed going to be compliant.

The other thing, selfishly, is that I want them to track, and maybe they already do, what they are seeing in terms of approvals, denials and subsequent reversals, so that we can actually have this baseline for when we finally lay the tracks. Back to your earlier question, did we actually make a difference by digitizing this? I almost want the before so that I can test the after. But I think it would behoove them too, because you can't manage what you can't measure. So measurement is key.

How do you want to leave it heading into 2027?

Banas: Let's do it again in six months and see if any of my predictions came true. But I do want to end on a positive note, and I do think we are starting to chip away, and I think that is a good thing.