- October 29, 2025
- Posted by: Josh Knoll
- Category: Prior Authorization
Prior authorization has always been a serious pain point for most healthcare providers and your practice is not an exception to it. We all know that the whole objective of prior authorization is to ensure that your proposed treatments are medically necessary. However, it frequently leads practices to face delays, denials and frustration. All the providers would be happy to know that change is on the way. All the federal and state bodies are now seriously evaluating how the whole process affects patient care, while major commercial insurance payers are promising to improve the system. Now, you should know what’s happening, what’s changing in the world of PA and what you should know before 2026.
The recent push for reform in medical prior authorization services:
Most healthcare providers have been urging for reform in the prior authorization process. The reason is simple- the process has become a major barrier to patient care instead of a cost-controlling method. You might have already noticed that prior authorization delays life-saving treatments and causes stress for both your patients and staff members. Almost every state is now taking efforts to improve laws and create better PA guidelines. It is really important to focus on making progress to make the process truly patient-centered and to do that, regulators should reduce unnecessary treatments, encourage care continuity, improve transparency and move towards automation.
Last year itself, major health insurance groups announced new plans to improve the prior authorization process. Over 60 insurers signed a pledge to make healthcare faster and simpler, making the commitments aligned with new federal regulations. Now, you should look at what changes they have proposed and when they plan to do it.
Know about the proposed changes and when to expect them to be implemented:
Related Reading: The Scary Truth about Prior Authorization Services
Standardize the electronic prior authorization process:
Health plans have agreed to build a clear and standardized electronic prior authorization system using FHIR APIs — a modern technology that helps providers and payers share data easily. Now, providers can expect potentially reduced paperwork, speedy responses and more convenient PA methods. You can expect this particular rule to be implemented from January, 2027.
Cut the scope of prior authorization:
Insurers offering ACA marketplace and Medicare Advantage plans will reduce the number of services that need prior authorization. The insurance payers are going to regularly review and update their lists based on the latest clinical data and patient needs as the goal is to make these changes by January 1, 2026.
Boost care continuity:
This change is very helpful for patients. You may find cases where a patient has switched their insurance plan and the new insurance payer must honor the old plan’s PA rules for at least 90 days. Your patient can continue their treatment without any delays as long as the service is covered by the new plan. Healthcare providers can expect this to happen from the starting in 2026.
Seamless communication with elevated transparency:
Insurers will now give clear reasons when a prior authorization is denied. Patients and providers will get simple explanations and instructions on how to appeal. Each health plan will also have staff to help patients understand what to do next after a denial.
Better real-time response:
Health plans want 80% of electronic prior authorization requests to get real-time responses. This means approvals will happen instantly when all documents are complete, enabling patients to get prompt access to urgent care and specialty drugs.
Promoting better clinical review:
Insurers now require that any prior authorization denial for medical necessity be reviewed by a licensed clinician. This rule is already active and helps make sure decisions are based on real medical facts, not just paperwork or administrative rules.
Now, you should know about the perspective of AMA regarding these changes.
AMA’s perspective about the upcoming changes:
No one can deny that these new commitments are positive steps moving forward but AMA has still shown concerns. The same types of promises were made before but progress has been slow. Now, the big question that pops out here is-would these reforms actually reduce care delays and administrative hassles? We have yet to see any clear directive to see any clear directive that would reform prescription drug authorization, causing problems for patients with chronic illnesses.
Prior authorization remains important as it is the only process for ensuring the care is medically essential and cost-justified. Many healthcare practices are facing delays and denials over small mistakes like missing codes or documentation in their prior authorization services. An efficient PA process always helps patients get timely care and ensures you are paid without delays. Let’s know about the seven key steps of prior authorization that a professional RCM company like SunKnowledge Inc. always implements.
The seven key steps of prior authorization services:
Step 1: Always gather accurate information
It is only possible to ensure a proper PA process when you know how to collect accurate patient details. You should always check patient demographics, provider information, procedure codes, and clinical documentation. Medical practices can always face PA rejection due to a single mistake in the documentation process. Your administrative team must double-check everything before submission.
Step 2: Contact the Payer
Each payer has its own way of handling authorizations. You can use an online portal if you have a budget, or else, you can use a manual process like fax or email. Your administrative team should always confirm if PA is required for a certain service and verify a patient’s eligibility before starting the PA initiation.
Step 3: Submit the Request for PA approval
Once you know what’s required, submit the request according to the payer’s rules. Include all supporting documents — such as CPT/ICD codes, notes, and lab reports. A complete and clean submission is your best defense against delays.
Step 4: Follow Up
Don’t assume silence means progress. Follow up regularly with the payer to check status updates. Most payers issue a tracking number — use it to stay informed and prevent your request from getting lost.
Step 5: Provide Extra Documents When Needed
You may find situations where payers ask for more information and you should always act fast when that happens. Coordinate with physicians and ensure you send everything promptly.
Step 6: Resubmit or Update as Requested
You should send documents to the payer using the same channel — fax, email, or portal when they ask for more information. Always reference the case ID so they can match your submission quickly.
Step 7: Record the Outcome
Once you receive the payer’s decision, update your system with all details — approval number, coverage dates, and any notes. If denied, record the reason clearly. It helps your billing team plan appeals effectively.
The harsh reality is that most healthcare practices, especially the medium and small ones, often lack an experienced team to handle their PA process efficiently. You can simply hire a professional RCM company like SunKnowledge to stay on top of this administrative task.
Related Reading: Are You in The Right Path with DME Prior Authorization?
SunKnowledge: Your One-Stop Destination for Healthcare Prior Authorization Services
SunKnowledge Inc. has been a trusted name in revenue cycle management company for over 17 years. We have dedicated teams for every stage of RCM, including prior authorization. With our help, providers can secure approvals faster and simplify their entire billing process. We maintain over a 97% first-pass approval rate for prior authorizations and claims, ensure high accuracy in every request, and offer our services at just $7 per hour. Our clients also save up to 80% on their operational costs. So, if you’re looking for expert help to get every prior authorization approved smoothly, reach out to us today. You can simply reach us by filling out our form available here, and our team will get in touch with a customized solution that works best for you.