# Prior Authorization * **Definition:** A process used by healthcare payers to determine if a healthcare service, procedure, or medication is medically necessary before it is provided, requiring healthcare providers to obtain approval from a health insurance company to ensure coverage. * **Taxonomy:** Healthcare Topics / Prior Authorization ## News * Selected news on the topic of **Prior Authorization**, for healthcare technology leaders * 4.9K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/21/2025 | [**From hours to minutes: AI transforms MetroHealth's pharmacy prior authorization process**](https://www.beckershospitalreview.com/pharmacy/from-hours-to-minutes-ai-transforms-metrohealths-prior-authorization-process/) | [[Beckers Hospital Review]] | | 5/16/2025 | [**How Payer-Provider Collaboration is Creating A More Patient-Friendly Healthcare Industry**](https://hitconsultant.net/2025/05/16/how-payer-provider-collaboration-is-creating-a-more-patient-friendly-healthcare-industry/) | [[HIT Consultant]] | | 4/23/2025 | [**ECU Health taps Force Therapeutics for care automation**](https://www.beckershospitalreview.com/care-coordination/ecu-health-taps-force-therapeutics-for-care-automation/) | [[Beckers Hospital Review]] | | 2/24/2025 | [**Physicians Concerned AI Increases Prior Authorization Denials, Worsens Patient Harms**](https://markets.businessinsider.com/news/stocks/physicians-concerned-ai-increases-prior-authorization-denials-worsens-patient-harms-waste-1034399710) | [[Business Insider Markets]] | | 2/24/2025 | [**careviso and XiFin Form Strategic Alliance to Modernize Prior Authorization -**](https://hitconsultant.net/2025/02/24/careviso-and-xifin-form-strategic-alliance-to-modernize-prior-authorization/) | [[HIT Consultant]] | | 2/19/2025 | [**careviso and XiFin Announce Strategic Alliance to Modernize Prior Authorization and Revenue Cycle Management to Speed Reimbursement and Improve Patient Access**](https://www.prnewswire.com/news-releases/careviso-and-xifin-announce-strategic-alliance-to-modernize-prior-authorization-and-revenue-cycle-management-to-speed-reimbursement-and-improve-patient-access-302380329.html) | [[PR Newswire]] | | 2/17/2025 | [**Availity 'Shifts Left' on Prior Authorizations at Vive - Morningstar**](https://www.morningstar.com/news/business-wire/20250217266883/availity-shifts-left-on-prior-authorizations-at-vive) | [[Morningstar]] | | 2/17/2025 | [**Availity 'Shifts Left' on Prior Authorizations at Vive - Yahoo Finance**](https://finance.yahoo.com/news/availity-shifts-left-prior-authorizations-130000554.html) | [[Yahoo Finance]] | | 2/12/2025 | [**Surescripts Unveils Innovative Touchless Prior Authorization Technology**](http://www.businesswire.com/news/home/20250212339102/en/Surescripts-Unveils-Innovative-Touchless-Prior-Authorization-Technology/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 2/12/2025 | [**Surescripts Unveils Innovative Touchless Prior Authorization Technology**](http://www.businesswire.com/news/home/20250212339102/en/Surescripts-Unveils-Innovative-Touchless-Prior-Authorization-Technology/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 2/12/2025 | [**Surescripts Unveils Innovative Touchless Prior Authorization Technology - Yahoo Finance**](https://finance.yahoo.com/news/surescripts-unveils-innovative-touchless-prior-130000988.html) | [[Yahoo Finance]] | | 2/5/2025 | [**The prior authorization reform push continues**](https://www.beckerspayer.com/payer/the-prior-authorization-reform-push-continues.html) | [[Beckers Payer]] | | 1/7/2025 | [**Do the New CMS Rules on Prior Authorization Go Far Enough?**](https://www.medpagetoday.com/practicemanagement/reimbursement/113683) | [[Medpage Today]] | | 12/4/2024 | [**Prior authorization delays lead to serious harm for people with cancer, nationwide survey finds**](https://medicalxpress.com/news/2024-12-prior-authorization-delays-people-cancer.html) | [[MedicalXpress]] | | 10/11/2024 | [**Racial and Ethnic Disparities in Prior Authorizations for Patients With Cancer**](https://www.ajmc.com/view/racial-and-ethnic-disparities-in-prior-authorizations-for-patients-with-cancer) | [[AJMC]] | | 9/18/2024 | [**The Critical Importance of Payer-Provider Collaboration Goes Beyond Prior Authorization**](https://hitconsultant.net/2024/09/19/the-critical-importance-of-payer-provider-collaboration-goes-beyond-prior-authorization/) | [[HIT Consultant]] | | 9/3/2024 | [**Enhancing Healthcare Efficiency with Utilization Management and Electronic Prior Authorization**](https://techbullion.com/enhancing-healthcare-efficiency-with-utilization-management-and-electronic-prior-authorization/) | techbullion.com | | 8/26/2024 | [**States Are Tackling Prior Authorization Reform - HealthLeaders Media**](https://www.healthleadersmedia.com/revenue-cycle/states-are-tackling-prior-authorization-reform) | [[HealthLeaders Media]] | | 8/14/2024 | [**What's it Going to Take to Fix Healthcare's Chronic Prior Authorization Pain?**](https://www.healthcareittoday.com/2024/08/14/whats-it-going-to-take-to-fix-healthcares-chronic-prior-authorization-pain/) | [[Healthcare IT Today]] | | 7/9/2024 | [**Improving the Prior Authorization Process: Recommendations for California**](https://www.chcf.org/publication/improving-the-prior-authorization-process-recommendations-for-california/) | [[California Health Care Foundation]] | | 7/8/2024 | [**CPT Code for Prior Authorization May Still Happen -- Eventually**](https://www.medpagetoday.com/practicemanagement/reimbursement/111002) | [[Medpage Today]] | | 6/17/2024 | [**AMA adopts new prior authorization reform policies**](https://www.healthcarefinancenews.com/news/ama-adopts-new-prior-authorization-reform-policies) | [[Healthcare Finance]] | | 3/13/2023 | [**Physicians Say Health Insurer Prior Authorization Is Rising And So Are Care Delays**](https://www.forbes.com/sites/brucejapsen/2023/03/13/physicians-say-health-insurer-prior-authorization-is-rising-and-so-are-care-delays/) | [[Forbes]] | | 10/12/2022 | [**Regence, MultiCare team on FHIR-enabled prior authorization**](https://www.fiercehealthcare.com/payers/regence-multicare-team-fhir-enabled-prior-authorization) | [[FierceHealthcare]] | | 5/28/2018 | [**prior authorization**](https://medcitynews.com/tag/prior-authorization/) | [[MedCity News]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Surescripts**: Provider of Touchless Prior Authorization technology aimed at automating workflows and reducing delays in patient access to treatments. - **Centers for Medicare and Medicaid Services (CMS)**: Federal agency implementing rules to enhance transparency and efficiency in the prior authorization process. - **Availity**: The largest real-time health information network in the U.S., showcasing intelligent authorization solutions to improve prior authorization processes. - **Optum Rx**: A healthcare technology provider that automates the prior authorization process for prescription drugs. - **American Hospital Association**: Advocates for reducing excessive prior authorization use and alleviating administrative burdens contributing to clinician burnout. - **American Medical Association**: Urges Congress to pass legislation reforming the Medicare Advantage prior authorization process. - **Valer**: A technology firm specializing in customized prior authorization solutions. - **UnitedHealthcare**: Plans to simplify prior authorization requirements for Medicare Advantage plans, emphasizing collaboration with policy leaders. - **Careviso**: A healthcare technology solutions provider that has completed over 2 million prior authorizations, enhancing patient access to healthcare services. - **CMS (Centers for Medicare & Medicaid Services)**: Government agency implementing new rules to reduce prior authorization denials in Medicare Advantage plans. - **Cohere Health**: A company that focuses on enhancing the prior authorization process through technology integration. - **AssureCare**: Provider of the MedCompass platform, which is compliant with CMS regulations for real-time prior authorization requests. - **American Medical Association (AMA)**: Advocates for reforms in prior authorization processes to alleviate administrative burdens on physicians and improve patient care. - **Medical Group Management Association**: Calls for the elimination of prior authorizations and greater transparency and standardization in the process. - **Humata Health**: Developed a fully touchless prior authorization process using AI technology to automate approvals. ### Partnerships and Collaborations - **Agadia and PromptPA**: Enhancing electronic prior authorization capabilities to streamline processes for specialty pharmacies and improve patient access. - **Humata Health and Allegheny Health Network**: Collaboration to implement a touchless prior authorization process, achieving high approval rates without human intervention. - **Blue Shield of California and Salesforce**: Collaborating to develop a prior authorization platform that integrates with physician systems for real-time authorization. - **Harmony Park Family Medicine and Humana**: They developed an end-to-end electronic prior authorization process to streamline approvals and enhance patient care. - **Availity and Concert**: Collaborating to automate and digitize prior authorization processes for genetic tests, aiming to enhance patient care and reduce administrative burdens. - **Surescripts and Cleveland Clinic**: Collaborating to streamline the prior authorization process, significantly reducing approval times and alleviating provider burnout. - **Cohere Health and MCG Health**: Partnership to enhance the prior authorization process by integrating clinical criteria and technologies. - **Keena Healthcare Technology and Valer**: Partnering to streamline manual prior authorization processes and improve efficiency. - **Valer and Clearwave**: This collaboration focuses on automating prior authorizations to reduce staffing burdens and improve patient access to treatments. - **Humata Health Funding**: Raised $25 million led by Blue Venture Fund and LRVHealth to enhance AI-driven prior authorization solutions. - **Infinx and Glidian**: Acquisition aimed at improving automation and operational efficiencies in prior authorizations. - **Parachute Health**: Partnered with major healthcare companies to enhance DME ePrescribing and prior authorization processes. - **VirtualHealth and Itiliti Health**: Launched the HELIOS® solution to streamline prior authorization and care management for healthcare payers. - **Careviso and XiFin**: Strategic alliance to integrate prior authorization services with revenue cycle management, improving operational efficiencies for diagnostic laboratories. ### Innovations, Trends, and Initiatives - **Optum Rx PreCheck**: An innovative solution that automates prior authorization for prescription drugs, significantly reducing approval times. - **Interoperability and Prior Authorization Rule**: CMS rule mandating digitized data and APIs to enhance interoperability and automate prior authorizations. - **Improving Seniors' Timely Access to Care Act**: A proposed bill aimed at establishing an electronic prior authorization process to enhance efficiency and transparency. - **CMS Prior Authorization Mandate**: Effective January 1, 2026, aimed at reducing administrative burdens and improving health information exchange. - **Touchless Prior Authorization Technology**: Surescripts' new technology that automates manual workflows, significantly reducing administrative burdens and expediting treatment initiation. - **Electronic Prior Authorization (ePA)**: The automation of prior authorization processes to reduce administrative burdens and improve patient outcomes. - **AI in Prior Authorization**: Payers are increasingly leveraging AI to enhance decision-making and operations in prior authorization, aiming for faster operations and improved collaboration. - **Touchless Prior Authorization**: Humata Health's initiative allows for automatic approvals of procedures through EHRs, significantly reducing administrative workload. - **CMS Final Rule**: Mandates prior authorization decisions within 72 hours for urgent requests and seven days for standard requests, effective January 1, 2026. - **Gold-Card Program by UnitedHealthcare**: Allows eligible in-network providers to bypass prior authorization requirements based on specific criteria. - **AI and Automation in Prior Authorization**: Companies like Humata Health are leveraging AI to streamline the prior authorization process, improving efficiency and reducing administrative burdens. - **CMS Interoperability and Prior Authorization Final Rule**: Mandates payors to implement specific FHIR APIs by January 2027 to improve healthcare data exchange and streamline prior authorization. - **Gold Card Program**: UnitedHealthcare's initiative to automatically qualify provider groups for streamlined prior authorization processes. - **Intelligent Authorization Solutions**: Availity's API-powered solutions aim to enhance decision-making speed and transparency in prior authorization processes. - **CMS New Rules (Effective January 2024)**: Aims to limit prior authorization use to confirming diagnoses and ensuring medical necessity, with a 90-day transition period for beneficiaries. ### Challenges and Concerns - **Administrative Burden**: Prior authorization processes are seen as a significant challenge for healthcare providers, leading to delays in patient care and increased operational costs. - **Delays in Patient Care**: Prior authorization processes are often criticized for causing delays in necessary medical treatments, negatively impacting patient outcomes. - **Impact on Patient Care**: Delays in prior authorization have been linked to negative patient outcomes, including treatment delays and increased hospitalizations. - **Provider Burden**: Providers face significant challenges with prior authorization processes, which can delay treatment and negatively impact patient outcomes. - **Patient Safety Risks**: 30% of radiation oncologists reported that prior authorization has led to emergency room visits, hospitalizations, or permanent disabilities. - **Physician Burnout**: The burdens of prior authorization contribute to physician burnout and dissatisfaction, impacting patient care. - **AI in Prior Authorization**: Concerns regarding the unregulated use of AI leading to increased denials and potential harm to patients, emphasizing the need for oversight. - **Confusion Among Patients**: Over 80% of patients experience confusion regarding prior authorizations, highlighting the need for improved communication in the healthcare system. - **Profit Over Patient Care**: Reports indicate that some Medicare Advantage insurers prioritize profits by using prior authorization to deny necessary post-acute care services. - **Treatment Delays**: Prior authorization processes are causing significant delays in cancer treatment, with 92% of oncologists reporting treatment delays. - **Denial Rates in Medicare Advantage**: High denial rates in Medicare Advantage plans have prompted calls for reform to streamline prior authorization processes. - **Administrative Burdens**: Despite some insurers reducing prior authorization requirements, many physicians still face significant administrative challenges. - **Health Disparities**: Research indicates disparities in prior authorization coverage for cancer patients based on race, highlighting the need for equitable practices. ## Related Topics [[Prior Authorization Issues]]