A year after major health insurers pledged to streamline prior authorization, physicians report the administrative burden remains as heavy as ever. The deadline for federal requirements that could force meaningful change is now less than five months away.
Colin Banas, MD, MHA, chief medical officer of DrFirst and the former chief medical information officer at VCU Health System, doubted the voluntary commitments when they were announced in June 2025. Asked if his skepticism was warranted, he did not hedge.
"I hate to say I told you so, but I feel a little bit vindicated," Banas said in an interview.
For practice managers, the gap between the industry pledge and the government mandate is the central operational story. The voluntary commitments carry no enforcement mechanism. The federal requirements arriving Jan. 1, 2027, do, and they place responsibility squarely on payers, EHR vendors, and practices through a new attestation measure.
Conflicting Reports on Progress
The pledge announced through AHIP contained six specific commitments. These included qualified clinical review of non-approved requests, a reduced scope of services subject to prior authorization, and honoring existing authorizations for 90 days when a patient changes plans. Insurers also promised clearer denial explanations and standardized electronic prior authorization using FHIR APIs by 2027.
The scorecard depends entirely on who is keeping it. AHIP and the Blue Cross Blue Shield Association reported in April that participating plans had eliminated 6.5 million prior authorizations, an 11 percent reduction. The trade groups stated that all participating plans have continuity of care programs in place.
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Physicians on the front lines report a different reality. The American Medical Association’s 2025 Prior Authorization Physician Survey found that only 24 percent of physicians say denials are consistently reviewed by a qualified clinician. Doctors reported completing an average of 40 prior authorizations per week. Nearly one-third said requests are often or always denied, and 94 percent said the process contributes to burnout.
Banas argued that the split in reporting is the core issue.
"A lot of the results are coming from the people who are making the pinky swear themselves," Banas said. "There’s no external validation."
For patients, this administrative stalemate translates to delayed treatments and hours spent on hold. The gap between a digital promise and a fax-machine reality means that while the technology exists to streamline care, the bureaucratic will to implement it uniformly is often absent. This creates a system where the efficiency of modern medicine is held hostage by outdated administrative workflows.
The Mechanics Remain Broken
Banas was blunt about the commitments regarding standardized electronic prior authorization and real-time approvals. He noted that both measures were already mandated by federal rules, making the industry pledge feel performative.
"It feels a little disingenuous," Banas said. "It feels like taking credit for something that you were going to have to do anyway."
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On the ground, the process has not improved. Friction from prior authorization is now overtaking EHR friction as the leading administrative irritant for doctors. Banas pointed out that many practices still rely on fax machines. Staff members often keep multiple browsers open to handle different portals for different payers and drugs.
"It’s all very much spaghetti," Banas said. "It’s all very much a non-unified experience."
He described retrospective prior authorization as the most avoidable version of this friction. This occurs when a patient learns at the pharmacy counter that approval is required, forcing a message back to the prescriber to start the process over. Banas called that scenario "almost insanity."
The 2027 Federal Mandate
The CMS Interoperability and Prior Authorization final rule requires affected Medicare Advantage, Medicaid, CHIP, and federally facilitated exchange plans to run four production FHIR APIs by Jan. 1, 2027. These include Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization.
Operational provisions have been in force since Jan. 1, 2026. These rules require seven-day decisions on standard requests and 72-hour decisions on urgent requests. Payers must also provide specific denial reasons and publicly report approval, denial, and turnaround metrics.
Two implementation details are critical for practice leaders. First, the 2027 APIs currently exclude drugs. CMS proposed a separate rule in April to extend electronic prior authorization to all drugs with a compliance date of Oct. 1, 2027. Second, the 2024 rule created a Promoting Interoperability measure for MIPS eligible clinicians tied to electronic prior authorization requests, making this a practice obligation rather than solely a payer one.
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Risks and Preparation
Banas fears the deadline will break down on the payer or vendor side. If technology vendors are ready to connect but payers are not, the system will revert to phone calls and faxes. He also worried about enforcement, comparing the situation to the early years of the information blocking rule when penalties were slow to arrive.
If the digital infrastructure is built and delays persist anyway, Banas believes the diagnosis will be clear.
"That the incentives are perverse," he said. "That all of this friction really was by design."
Some areas are improving. Banas credited payers for expanding "gold carding," which exempts clinicians with consistent approval histories from repeat authorizations. He also pointed to automation wins in GLP-1 prescribing workflows that satisfy payer criteria in the background.
He advised practice managers to take two immediate steps. They should call their EHR or e-prescribing vendor to get a straight answer on compliance with the Jan. 1, 2027 requirements. Managers also need to build a baseline now by tracking current approvals, denials, and reversals.
"You can’t manage what you can’t measure," Banas said. "So measurement is key."
