Prior Authorization Reform Is Finally on the Table — Standards Must Be Too

For decades, Americans have endured a healthcare system where access to care is delayed not by clinical need, but by administrative demands with little benefit. Prior authorization, the process insurers use to determine whether a medical service will be covered, has become one of the leading causes of care delays, clinician burnout, and patient frustration.

Recently, the Department of Health and Human Services (HHS), alongside more than 45 of the nation’s largest health insurers, announced a shared commitment to modernize and streamline prior authorization by 2027. The goal: fewer delays, faster and more transparent decisions, and a fairer experience for patients and providers alike.

It’s a meaningful step. But declarations alone won’t fix a system still powered by fax machines, phone calls, and inconsistent rules. Real progress will require a modern digital infrastructure, aligned incentives, and coordinated action across both the public and private sectors.

Providers must adopt tools that support streamlined, automated workflows. Software vendors must implement interoperable application programming interfaces (APIs) that work across platforms and organizations. And policymakers must ensure these reforms deliver real results by rewarding outcomes, enforcing accountability, and investing in scale and adoption support.

Fortunately, the Centers for Medicare & Medicaid Services (CMS) has laid the groundwork. Proposed regulations would require Medicare, Medicaid and Marketplace health plans to implement APIs and provide faster decisions on prior authorization requests. These rules build on years of bipartisan investment in health IT and create the foundation for modernization.

A key component of this digital transformation, as highlighted this week by HHS, is the adoption of Fast Healthcare Interoperability Resources (FHIR®), a universal data standard that enables secure, scalable, real-time exchange of health information. Already embedded in many public and private programs, FHIR makes it possible for clinicians and payers to exchange data, automate workflows, and accelerate access to treatment.

Yet, standards only matter if they are implemented consistently and equitably. Ultimately, that is the reason that public-private collaboration must prioritize adoption across all care settings, including smaller practices, rural clinics, and safety-net hospitals. 

Healthcare reform must close care gaps, not widen them. Although large health systems have the resources to adopt new technologies, many community health clinics and rural providers do not. To avoid deepening disparities, policymakers must invest in infrastructure, workforce training, and technical assistance that bring all providers and patients into the digital future.

It’s time to acknowledge what clinicians and consumers have long known: that a process meant to ensure appropriate care has too often devolved into treatment delays, clinician burnout, and loss of trust.

Reversing that trend won’t happen overnight, but it can happen with shared accountability and sustained investment. Interoperability and data standards must be treated not as private intellectual property, but as critical public infrastructure, as important to healthcare delivery as roads, power grids, or clean water.

The building blocks are already in place. The data standards exist. The technology exists. So do the testing frameworks and governance models. What’s needed now is implementation at scale, and a unified commitment across constituents to make it work.

The success of prior authorization reform won’t be measured by how fast approvals come through, but by how fairly and reliably patients can access the care they need. 

The foundation is there. Now we must build on it, together.

Photo by Mark Wilson/Getty Images

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