Some payers worry about meeting Jan. 1 electronic prior authorization deadline, MGMA says

Some insurers have raised concerns about meeting the Jan. 1, 2027, deadline to support electronic prior authorization in Medicare Advantage (MA) and Medicaid, according to the Medical Group Management Association (MGMA).

Insurers describe the work in three steps, Madison Hynes, M.P.P., an associate director of government affairs at MGMA, said Sept. 27 at the MGMA Annual Conference 2026 in San Antonio.

Practices first need to be able to see in their electronic health record (EHR) whether a service requires prior authorization. Plans then have to supply documentation templates electronically. The last step is transmitting the request itself.

"What we've heard from some insurance companies is that there's concerns about them being able to implement all three of those steps by January 1," Hynes said.

MGMA is pushing back against any delay, she said, and wants practices to have the resources to use electronic prior authorization through their EHR vendors. The deadline comes from a Centers for Medicare & Medicaid Services (CMS) rule, CMS-0057, whose first provisions took effect this year.

What's already required

Since January, MA and Medicaid plans have had to decide standard prior authorization requests within seven days and expedited requests within 72 hours. They must also give a specific reason when they deny a request.

"We are anxious to see if that is really being implemented on the ground," Hynes said.

Plans began publicly reporting prior authorization metrics, including denial rates, earlier this year. Some insurers may be posting the data "as a CSV file on some backend website that's not accessible," Hynes said.

MGMA wants CMS to collect and publish the numbers so practices don't have to search a dozen payer websites to decide whether a contract is worth pursuing.

Dozens of health plans pledged last year to reduce prior authorization, including in commercial coverage. Member feedback to MGMA is that the commitments aren't being carried out, Hynes said. MGMA hopes plans will extend the MA and Medicaid timelines to commercial coverage, she said, though she acknowledged that is a long shot.

In MGMA's 2026 regulatory burden report, 90% of practices said prior authorization requirements had increased over the past year. MGMA takes the report to congressional offices. Hynes said a detail such as a practice hiring four more back-office staff members in a year to handle prior authorization "does stick" there.

Traditional Medicare and MIPS

Since January, technology companies have used artificial intelligence to review prior authorization requests for select traditional Medicare services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.

They do so under the CMS Innovation Center's Wasteful and Inappropriate Service Reduction model, known as WISeR. A few attendees raised their hands when Hynes asked who had encountered it.

"The expansion of prior authorization in traditional Medicare is not what we want to see, given it is one of the biggest burdens of Medicare Advantage," Hynes said. MGMA is also concerned about "the incentive of these technology companies to deny care," she said, because denials generate savings for the government and can raise the companies' own reimbursement.

The electronic prior authorization measure in the Merit-based Incentive Payment System's Promoting Interoperability category would be optional at first under the proposed 2027 physician fee schedule, said James Haynes, J.D., also an associate director of government affairs at MGMA.

In Congress

The Improving Seniors' Timely Access to Care Act, which would codify some of the MA prior authorization rules, has 290 House cosponsors, Hynes said.

"You don't get more than that," she said. "It's a vast supermajority."

The bill has been introduced in prior Congresses, carries little to no cost and has more momentum now, Hynes said. MGMA also supports the Reducing Medically Unnecessary Delays in Care Act and is watching electronic prior authorization for drugs. Federal funding runs out Dec. 11, and Hynes said the Seniors' Act is "something that we could see sneak into an end of year funding package."

Physicians Practice is in San Antonio at the MGMA Annual Conference, Sept 27-30, celebrating 100 years of MGMA, attending sessions and speaking with industry leaders. Follow our coverage on our MGMA conference page.