Reforming Prior Auths: A Turning Point

Reforming Prior Auth: A Turning Point
Seen by many as crucial to efficient healthcare delivery and timely reimbursement, prior authorization reform is gaining momentum—and providers need to be ready.

Will 2025 Be the Year We Fix the Prior Authorization Delays? In the ever-evolving world of healthcare reimbursement, prior authorization delays have become one of the most frustrating bottlenecks for providers, patients, and revenue cycle teams alike. With mounting pressure on CMS and commercial payers, we are all hopeful that 2025 could be the year we see meaningful prior authorization reform—and for healthcare organizations, the impact could be significant. We’re closer than we’ve ever been—but it’s not guaranteed.   For years, prior authorization (PA) has been a time-consuming, manual process that slows down care delivery, frustrates providers, and delays reimbursement. In many cases, approvals that should take hours can drag on for days—or even weeks—leading to denied claims, rescheduled procedures, and revenue cycle disruption.

Why Prior Authorization Reform Is Gaining Momentum

Now, CMS has proposed new rules aimed at modernizing the prior authorization process. These changes would require payers to adopt electronic prior authorization systems (ePA), provide faster turnaround times, and improve transparency. Commercial payers are also facing increasing scrutiny from lawmakers, professional associations, and advocacy groups demanding better accountability and fewer administrative burdens.

✅ 1. CMS Has Issued a Final Rule (Yes—Final)

In January 2024, CMS finalized the “Interoperability and Prior Authorization Final Rule (CMS-0057-F)”.   It’s a real regulation that requires certain payers to implement electronic prior authorization (ePA) workflows by January 1, 2027. So yes—federal momentum is real. But that doesn’t mean private payers are moving just as fast.

Physician associations like AMA, MGMA, and AHA are pushing hard for commercial payers to adopt similar standards.

• Bipartisan legislation introduced in Congress: “The Improving Seniors’ Timely Access to Care Act”, which aims to codify these reforms across the board.
• Widespread lobbying for greater transparency and penalties for payers that delay care.

While CMS can mandate changes for government-sponsored plans, commercial payer adoption is still voluntary—but under pressure.

🏥 3. Payers Are Piloting Solutions (But It’s Slow)

Some commercial payers, have started implementing AI-driven or automated prior auth tools. But adoption is uneven:

• Some have narrowed their prior auth lists (e.g., removing PA requirements for certain services).
• Others are piloting automated approval systems to reduce manual work.

But overall, transparency is still limited, and provider experience varies widely.

🚧 So What’s the Catch?

Even with CMS rules and mounting pressure:

• Commercial payers aren’t legally required (yet) to comply.
• Providers will need tech upgrades to integrate ePA platforms.
• Operational readiness varies drastically by payer and region.

📣 What Providers Can Do Now:

1. Track your own PA pain points—know your denial rates, turnaround times, and payer trends.
2. Start exploring ePA tools now—vendors are already developing integrations.
3. Work with a consulting partner (like Legacy) to audit your workflows and prep for what’s coming.
4. Advocate—join efforts through associations to push for broader reform.

🎯 Bottom Line:

At Legacy Consulting Services, we understand how prior authorization challenges directly affect a provider’s ability to generate clean claims, manage denials, and accelerate reimbursement. That’s why we are closely watching these reforms and helping our clients stay ahead of the changes.

The Financial Impact of Prior Authorization Delays

Prior authorization isn’t just a clinical headache—it’s a revenue cycle roadblock.

• Delayed Authorizations = Delayed Billing: When procedures or medications are held up by prior auth, billing is paused. This causes cash flow delays and puts pressure on AR teams.
• Increased Denials: Missing or delayed prior auths lead to claim denials, rework, and lost revenue.
• Administrative Burden: Staff often spend hours on the phone or faxing documentation, reducing productivity and increasing overhead.

By streamlining this process, providers can reduce claims lag time, minimize denials, and better manage their accounts receivable performance.

How Legacy Consulting Services Can Help

At Legacy Consulting Services, we support providers, hospitals, and medical groups by helping them streamline operations, reduce reimbursement delays, and maintain compliance with payer policies. When it comes to prior authorizations, we can:

• Audit your current prior authorization workflows to identify gaps and opportunities for automation
• Train front-end staff on best practices for documentation, submission, and follow-up
• Implement KPI tracking to monitor prior auth turnaround times, approval rates, and denial trends
• Support electronic prior authorization transitions in preparation for new CMS mandates

Our goal is to empower your team with efficient, compliant systems that reduce revenue leakage and support timely, accurate reimbursement.

Don’t Wait for Reform—Get Ahead of It

Whether or not the CMS rules go into effect in 2025, the pressure on prior authorization reform is building. Proactive practices and health systems that optimize their processes now will be in a better position to protect their revenue cycle and deliver timely patient care.

Let Legacy Consulting Services help you evaluate your prior authorization process and implement changes that make an immediate impact.

👉 Contact us today for a consultation or to learn more about how we can help your team prepare for what’s next in healthcare reimbursement.