Visit any playground with children playing tag, hide-and-seek or any other game, and you’ll learn that rules matter. When kids understand and follow the agreed-upon rules, they have fun and learn to cooperate and respect their teammates and opponents — whether they win or not.
Without that set of simple, clear and agreed-upon rules, a friendly game of freeze tag can transform quickly into a chaotic wrestling match. And ultimately, there are rarely any real winners.
The same is true in healthcare delivery, for providers and patients alike. Unfortunately, navigating the world of prior authorizations can feel like a game with constantly shifting rules — a frustrating experience that many of us can relate to. This time, though, we are playing a “game” that affects our livelihood or even our very lives.
The Challenges of Prior Authorization for Providers and Patients Alike
In the ever-evolving world of healthcare revenue cycle management (RCM), prior authorizations have changed from a minor annoyance to a major roadblock — in clinical terms, they have become a chronic wound that never seems to heal. Payers can change the rules mid-game with little to no repercussions, making prior authorizations a persistent frustration for both providers and patients. The process today has become complex, time-consuming and delays the delivery of care. The process has become complex, time-consuming and prone to delaying care. This dynamic frustrates everyone and can endanger both provider financial stability and patient outcomes.
Even after providers meticulously follow all the protocols to authorize a medical procedure, payment is never guaranteed. This uncertainty creates an uneven playing field, putting providers at a disadvantage.
And to make matters worse, payers can suddenly change the rules with little notice. In March 2023, UnitedHealthcare decided that diagnostic and preventive colonoscopies required prior authorization, leaving gastroenterologists scrambling. While the payer eventually backtracked after a widespread outcry, it remains another stark reminder that payers have the upper hand.
There have been times when it felt as if even our experienced Advantum Health team needed post-graduate medical degrees to determine whether and when patients would get their procedures authorized and providers reimbursed.
Prior Authorizations Made Sense…Until They Didn’t
Prior authorizations began to be mandated in the 1960s and ’70s, originating from utilization reviews used in early Medicare and Medicaid. The original intent was logical:
- Payers could control costs
- Provider organizations of all sizes could ensure medical necessity
- Patients could receive appropriate and timely care.
It was designed as a system of checks-and-balances system.
But that system has drifted far off course.
Citing JAMAs report on “Waste in the U.S. Healthcare System,” the Journal of the American Medical Association (AHIP), notes that “an estimated 25% of U.S. healthcare spending is considered unnecessary due to overtreatment, use of low-value care, lack of care coordination, outdated technology, and fraud.”
Over time, the prior authorization process became overly burdensome, riddled with inconsistencies and often resulting in delay or denied necessary care. This shift has left providers and patients feeling frustrated and unheard.
However, growing media and government attention is a positive sign. It means the flaws are being acknowledged and efforts toward reform are underway.
The (Hopeful) Future of Prior Auth: Six Steps to Balance Costs and Patient Care
In June 2025, more than 60 health insurers — through AHIP and the Blue Cross Blue Shield Association — commited to six steps designed to simplify prior authorization. These recommendations were presented to the heads of the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS). Several elements now appear in recent CMS rules.
The six steps include:
- Standardize electronic prior authorization. Today, nearly half of prior authorization requests are submitted manually by phone, fax or mail. Goal: Jan. 1, 2027.
- Reduce the scope of prior authorization for plans through the Affordable Care Act and Medicare Advantage as appropriate. Goal: Jan. 1, 2026.
- Ensure continuity of care on benefit-equivalent prior authorizations when patients switch health plans. Goal: Jan. 1, 2026.
- Improve communication and transparency around prior authorization denials. Goal: Jan. 1, 2026.
- Expand near-real-time responses on prior authorization requests submitted electronically. Goal: Jan. 2, 2027.
- Require medical review of denials by a qualified clinician. Goal: in effect now.
The Impact of OBBA on Prior Authorizations and Healthcare Overall
In July, the president signed the One Big Beautiful Bill Act (OBBBA). Several provisions will significantly impact how providers deliver care and get paid. Some changes will be felt immediately; others will roll out over time (See PDF from the Advisory Board on OBBBA’s potential effects on healthcare).
One example: OBBBA now requires Medicaid eligibility redeterminations every six months for adults covered by Patient Protection and Affordable Care Act (ACA, aka “Obamacare”) state Medicaid expansions. The industry is expected to be impacted by more-frequent administrative work to determine continued eligibility.
While not part of the OBBBA itself, CMS is also launching a Wasteful and Inappropriate Service Reduction Model (WISeR). The voluntary model is scheduled to run from Jan. 1, 2026, through Dec. 31, 2031, in six states, using artificial intelligence and machine learning with private companies to manage prior authorization requests for Medicare services. States announced to participate include New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.
Advantum continues to monitor these developments and will advocate for clients accordingly.
The Smarter Way to Outsource Prior Authorization Services
In the complex world of healthcare, payer contracts can make or break healthcare providers, especially independent physician groups. It’s a high-stakes game where the rules are often stacked against providers, and prior authorizations are a prime example.
As a dedicated RCM partner, Advantum remains laser focused on payer changes — down to the plan level — and responds immediately. These are integrated into our prior authorization best practices as the market evolves.
As noted above, the impact on the healthcare system — for providers, patients and payers — is increasingly evident. Hopefully, this increased visibility will pave the way for a more transparent and equitable system.
Learn more about how Advantum Health partners with hundreds of provider organizations across all specialties and sizes to streamline prior authorizations and bring clarity to payer requirements. Contact us today