Prior authorization a year after the insurer pledge: what practices need before Jan. 1, 2027

A year after dozens of health insurers pledged to streamline prior authorization, physicians say the process feels no better, and the deadline that could actually force change is less than five months away.

Colin Banas, MD, MHA, chief medical officer of DrFirst and the former chief medical information officer at VCU Health System, doubted the voluntary commitments when insurers announced them in June 2025. Asked whether he was right, he did not hedge.

"I hate to say I told you so, but I feel a little bit vindicated," Banas said in an interview with Physicians Practice.

For practice managers, the gap between the pledge and the mandate is the operational story. The voluntary commitments carry no enforcement. The federal requirements arriving Jan. 1, 2027, do, and they land on payers, on EHR vendors and, through a new attestation measure, on practices themselves.

What did insurers promise, and what have they delivered?

The pledge announced through AHIP in June 2025 contained six commitments: qualified clinical review of non-approved requests, a reduced scope of services subject to prior authorization, honoring existing authorizations for 90 days when a patient changes plans, clearer denial explanations, standardized electronic prior authorization using FHIR APIs by 2027, and real-time answers on at least 80 percent of electronic approvals in 2027.

The scorecard depends on who is keeping it. AHIP and the Blue Cross Blue Shield Association reported in April that participating plans had eliminated 6.5 million prior authorizations, an 11 percent reduction, and the trade groups say all participating plans have continuity of care programs in place.

Physicians report something different. The AMA's 2025 Prior Authorization Physician Survey, released in May, found that only 24 percent of physicians say denials are consistently reviewed by an appropriately qualified clinician, the one commitment that took effect immediately. Physicians reported completing an average of 40 prior authorizations per week, 32 percent said requests are often or always denied, 94 percent said the process contributes to burnout and just 33 percent said they believe the pledge will make a meaningful difference.

Banas said that split is the whole problem.

"A lot of the results are coming from the people who are making the pinky swear themselves. There's no external validation," he said. "If anything, the external validation would come in the form of what my peers are seeing on the front lines."

He was blunter about the two commitments that matter most to him, standardized electronic prior authorization and real-time approvals, because both were already coming by federal mandate.

"To make a pinky swear saying, 'Hey, we're going to do this,' when in the background you're being forced to do this, at least in the CMS payer community, I don't know," Banas said. "It feels a little disingenuous. It feels like taking credit for something that you were going to have to do anyway."

Does the process feel any better on the front lines?

"It's as bad as ever," Banas said. He pointed to a shift in what physicians name as their leading administrative irritant: "The PA friction is actually overtaking the EHR friction."

The mechanics have not changed much either.

"I still see rooms with fax machines, which is unbelievable, and dedicated clinical teams with multiple browsers open because they're interacting with different portals for different payers and different drugs, and so it's all very much spaghetti," Banas said. "It's all very much a non-unified experience, and it's wasteful."

The most avoidable version of that friction, he said, is the retrospective prior authorization, when a patient learns at the pharmacy counter that approval is required and a message has gone back to the prescriber to start the process. Banas called that "almost insanity."

Outside reporting points the same direction. KFF Health News reported in July that some insurers now say they will not implement every piece of the pledge, and quoted Rep. Greg Murphy, R-N.C., a physician who co-chairs the GOP Doctors Caucus, saying the commitments have "no teeth." AHIP responded that the reporting was incomplete and that plans remain on track.

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

The CMS Interoperability and Prior Authorization final rule, CMS-0057-F, requires affected Medicare Advantage, Medicaid, CHIP and federally facilitated exchange plans to run four production FHIR APIs by Jan. 1, 2027: Patient Access, Provider Access, Payer-to-Payer and Prior Authorization. Operational provisions have been in force since Jan. 1, 2026, including seven-day decisions on standard requests, 72 hours on urgent requests, specific denial reasons and public reporting of approval, denial and turnaround metrics.

Banas described the same four pipes from the practice side: a way to pull a payer's question set and submit a request, a payer-to-payer handoff when a patient switches plans, a patient-facing view of the rules, and the authorization transaction itself.

Two things practice leaders should not miss. First, the 2027 APIs exclude drugs. CMS proposed a separate rule in April, CMS-0062-P, that would extend electronic prior authorization to all drugs with a proposed compliance date of Oct. 1, 2027, while Part D prescribing moves to newer NCPDP formulary, benefit and real-time benefit standards beginning Jan. 1, 2027. Second, the 2024 rule created a Promoting Interoperability measure for MIPS eligible clinicians tied to electronic prior authorization requests, beginning with the 2027 performance period. That one is a practice obligation, not a payer obligation.

Where is the deadline most likely to break down?

"If I had to guess, it would be on the payer or maybe even the vendor side," Banas said. "I know at DrFirst we're 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's sort of all for naught, and it's going to break down back to the current process, which is a lot of phone calls and faxes."

His second worry is enforcement. He compared the coming deadline to the early years of the information blocking rule.

"For at least two plus years of the initial info blocking rule, nothing was really happening to the bad guys," Banas said. "So I hope we don't make that same mistake here."

If the pipes get built and delays persist anyway, he said, the diagnosis writes itself.

"That the incentives are perverse. That all of this friction really was by design, which I really don't want that to be true," Banas said. "If you digitize it all and the process is still broken, then the process was the problem all along."

Is anything actually getting better?

Some things are. Banas credited payers expanding gold carding, which exempts clinicians with consistent approval histories from repeat authorizations, and pointed to narrow automation wins, including GLP-1 prescribing workflows that satisfy payer criteria in the background and avoid the authorization entirely.

"We might not be able to get 100 percent of the PA done via automation, but we can get 80, and if I can take 80 percent of the work off of 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's actually still meaningful progress," Banas said.

What he wants from the 2027 build is simpler than any of that.

"If I had to pick one word, it would be transparency for all involved," he said, comparing it to watching a pizza order move across a delivery app. "I want the patients and the providers to have that as well."

What can a practice manager do this month?

Banas gave two assignments, and both are cheap.

Call the EHR or e-prescribing vendor and get a straight answer on where it stands against the Jan. 1, 2027 requirements and the NCPDP standards work behind it.

"You really need to be on top of them to make sure that they are indeed going to be compliant," he said.

Then build a baseline. Track current approvals, denials and subsequent reversals so the practice can tell in 2027 whether digitization actually moved anything.

"I almost want the before so that I can test the after," Banas said. "You can't manage what you can't measure. So measurement is key."

That baseline is also leverage. Practices that can document turnaround times and overturn rates going into the deadline will be better positioned to escalate with payers, hold vendors to their timelines and answer the question the pledge never did.