MGMA warns payers against backing out of the Jan. 1 prior authorization deadline

Payers have three months to put new prior authorization connections into production, and MGMA's top lobbyist says most practices haven't heard a word about it from the vendors that are supposed to plug them in.

Anders Gilberg, senior vice president of government affairs at MGMA, said he has started to worry that health plans are treating the deadline loosely. "I've been hearing some rumblings," Gilberg told Physicians Practice during MGMA's 100th Annual Conference in San Antonio, adding that he is concerned "that perhaps the payers aren't taking this as seriously as they should."

The deadline comes from the CMS Interoperability and Prior Authorization final rule, CMS-0057-F. According to the CMS fact sheet on the rule, Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed care plans and exchange plans on the federal marketplace must stand up a Prior Authorization API generally beginning Jan. 1, 2027, with exact dates varying by payer type. The API must list the items and services that need authorization, spell out the documentation each one requires and accept a request and send back an approval, a denial with a specific reason or a request for more information.

The rule's operational half took effect Jan. 1, 2026, with 72-hour decisions on expedited requests and seven-day decisions on standard ones. Gilberg said the bigger change is still ahead. "The real promise is in 2027," he said.

That promise is a request built inside the chart. A physician with a patient in the room would identify a few discrete data points and "submit the prior authorization right then and there through the EHR," Gilberg said. "For the first time, it standardizes prior authorization requests out of an EHR."

It would also take away the reason practices still run fax machines, he said. "One of the most frustrating things I hear is that physicians want to use the fax machine," Gilberg said. "The reason they need the fax machine is there's no way to transmit clinical information."

Payers have spent years faulting physicians for incomplete documentation, he said, and the API is built to fix exactly that. "For all their pledges and commitments to fixing prior authorization, I think this is one of the most important things," Gilberg said. "For them to back out at the 11th hour saying it's not ready for prime time would be unacceptable in our view."

Few practices have heard from their vendors

MGMA staff spent part of the conference asking members whether their EHR vendors had raised the deadline. Very few had heard much, Gilberg said.

MGMA plans to send members "a real list of questions and a checklist" to put to their EHR vendors as the date gets closer, he said. The association already has a member-only resource on payer API technical requirements and practice readiness, published Aug. 3.

The 2026 deadlines have not delivered much relief so far. In a Sept. 1 MGMA Stat poll, 44 percent of medical group leaders said prior authorization had gotten slower than in 2025, and 7 percent said it was faster.

What practices can do before Jan. 1

The rule regulates payers, not practices, but practices have a stake beyond convenience. Starting with the 2027 performance period, MIPS eligible clinicians must attest to an Electronic Prior Authorization measure under Promoting Interoperability, confirming they requested at least one authorization through a Prior Authorization API using certified EHR data or claiming an exclusion, according to the CMS fact sheet.

That makes the vendor conversation a 2027 reporting question, too. Administrators can ask now which of their payers the vendor has connected to, when the functionality will reach their version of the software and what it will cost. The Physicians Practice prior authorization handbook includes a vendor question list and a payer readiness call script.

Gilberg said MGMA will keep the pressure on payers through the deadline. "We're going to be really pushing hard for this implementation," he said.