Health plans and pharmacy benefit managers (PBMs) increasingly require healthcare professionals to obtain prior authorization (PA) before providing medical services or prescriptions. PA remains the top administrative burden reported by medical group practices, with the greatest prevalence in Medicare Advantage (MA) plans.

Prior authorization requests delay critical care and treatment for patients, and MA insurers in particular have shown high rates of inappropriate denials.¹ In MGMA’s Annual Regulatory Burden Report, 92% of surveyed medical group practices reported hiring or reassigning staff solely to handle the growing volume of PA requests, resources that could otherwise go toward patient care, such as hiring a nurse or expanding service hours. 

Six in 10 (60%) practices indicated that at least three employees are typically involved in completing a single PA request, while 35% reported spending upwards of 35 minutes on average per request.² This is especially problematic for independent practices, particularly in rural and underserved areas, that already struggle to stay afloat. Rising operational costs, increasing regulatory complexity, and staffing shortages have forced many
practices to close, reducing access to care in communities that need it most. 

MGMA strongly supports commonsense policy solutions to PA that reduce administrative burden, increase transparency, and protect the sustainability of medical group practices, ensuring clinicians can focus on patients, not paperwork. In collaboration with the provider community and other stakeholders, MGMA has successfully worked with policymakers to advance these interests through regulations, legislation, and by securing commitments from the health insurance industry to reduce the burden of PA.

This article provides an overview of the PA landscape in 2025 through some of these policy vehicles, how medical group practices can prepare for future changes, and how you can help MGMA continue its advocacy efforts to reform PA.

Regulations

CMS Interoperability and Prior Authorization Final Rule (Jan. 17, 2024):

Who’s covered: MA organizations, Medicaid/CHIP Fee-for-Service and managed care, and Qualified Health Plan (QHP) issuers on the federally facilitated exchanges (FFE) must implement new data-sharing capabilities and streamlined PA processes.

Decision Timeframes:

• Expedited (urgent) PA requests: Decisions due within 72 hours (excluding QHP issuers on FFEs) beginning Jan. 1, 2026.
• Standard (non-urgent) PA requests: Decisions due within seven calendar days beginning Jan. 1, 2026.
• Denials: Must include a specific reason (regardless of submission channel) beginning Jan. 1, 2026.
• Public reporting: Plans must post PA metrics annually; first reports due by March 31, 2026

Application Programming Interfaces (APIs):

Impacted payers must establish an electronic prior authorization process referred to as the Prior Authorization API. They must also set up and maintain APIs for the transmission of certain prior authorization and other information to different parties — these are referred to as the Patient Access API, Provider Access API, and Payer-to-Payer API. These APIs must be implemented by Jan. 1, 2027 (with some usage metric reporting beginning Jan. 1, 2026).

CMS also created a Promoting Interoperability measure requiring clinicians and hospitals to attest to submitting at least one electronic PA via API starting with calendar year 2027 performance.

Relevant Guiderails Already in Place:

Contract Year (CY) 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly final rule³ clarified that MA coverage criteria must align with national coverage determinations, local coverage determinations, and Traditional Medicare except in limited, transparent cases. Plans must provide a 90-day transition period when a patient changes plans during which the new MA plan may not require prior authorization for an active course of treatment. 

PA approvals for a course of treatment must also remain valid as long as medically reasonable and necessary. Plans must maintain a Utilization Management Committee to review PA policies annually.

Bottom Line for Medical Group Practices:

Over the course of 2026–2027, medical group practices can expect faster decisions, clearer denials, and more payers capable of receiving and returning PA decisions electronically. MGMA supported many of the commitments from this CMS Interoperability and Prior Authorization Final Rule⁴; however, during the comment period of the proposed rule, MGMA pushed for shorter decision timeframes than outlined in the final rule so that prior authorization requests are processed in a timely manner as to not delay care.⁴

Legislation

Improving Seniors’ Timely Access to Care Act of 2025- S.1816/H.R.3514 (Seniors’ Act): This bipartisan and bicameral legislation would protect seniors from unnecessary delays and denials of medically necessary care by streamlining and standardizing PA in MA. The bill was first introduced in Congress in 2019 and has been reintroduced in subsequent Congresses, and passed in the House of Representatives in 2022; however, it did not advance to the Senate before the end of that term. While it has yet to be enacted, some of its provisions influenced regulatory action cited above in the CMS Interoperability and Prior Authorization Final Rule.

Transparency: Health plans would submit PA metrics (such as volumes, approvals/ denials, appeals, and turnarounds) to be published by CMS. Plans would share criteria with contracted providers and, on request, enrollees starting in plan year 2027.

Electronic PA and enrollee protections: Secure electronic (not fax or basic portals) PA capabilities, with standards to support automation and real-time decisions for routinely approved services, starting in plan year 2028, which is consistent with the API requirements in CMS Interoperability and Prior Authorization Final Rule.

Accountability: CMS would report to Congress on defining and implementing real-time determinations and describing how it could apply to routinely approved items and services under electronic PA. The report must also analyze which services could qualify, whether real-time decisions could improve enrollee access, create operational efficiencies, and reduce disparities for rural and low-income MA beneficiaries, by Jan. 1, 2028. The Government Accountability Office would also submit to Congress a report containing an evaluation of these implementation efforts no later than January 1, 2032.

How it pairs with current regulations: The CMS Interoperability and Prior Authorization Final Rule is intended to accelerate technology adoption and shortens decision timelines across MA and Medicaid/CHIP. The Seniors’ Act would apply specifically to the particularly burdensome MA PA requirements, as noted in MGMA’s Regulatory Burden Survey. 

By codifying transparency, electronic processes, and patient safeguards in statute, the Seniors’
Act would make these protections harder to roll back and easier to enforce. This is particularly critical after the Supreme Court’s Loper Bright Enterprises v. Raimondo (2024) decision, which overturned Chevron v. NRDC (1984) and eliminated judicial deference to agency interpretations of ambiguous statutes. Without Chevron, CMS faces greater legal risk, as insurers may argue the agency lacks clear statutory authority. 

The Seniors’ Act directly addresses this concern by explicitly designating the HHS Secretary’s authority to set rules for how insurers decide prior authorization requests, thereby minimizing ambiguity, reducing opportunities for legal challenges, and strengthening CMS’ ability to enforce patient protections. MGMA worked closely on the development of the bill and has been working with other stakeholders to advocate for the Seniors’ Act
to members of congress to pass this important legislation.⁶

2025 Health Insurance Industry Pledge

On June 23, 2025, HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz joined a coalition of insurers, including Aetna, Cigna, Elevance, Humana, UnitedHealthcare, and multiple Blue Cross Blue Shield plans, in announcing a voluntary pledge to reform PA across employer, commercial, Marketplace, Medicare Advantage, and Medicaid markets.⁷ This pledge aligns with much of what is required in the CMS Interoperability and Prior Authorization Final Rule but extends commitments to commercial and employer plans outside CMS’ regulatory authority, ultimately impacting eight out of 10 Americans.

The six commitments are:

• Ensure only medical professionals review nonapproved PA requests, effective immediately.
• Reduce the volume of services requiring PA, with measurable reductions by Jan. 1, 2026.
• Honor existing PAs during insurer transitions, with a 90-day continuity period beginning Jan. 1, 2026.
• Improve explanations for PA denials and appeals processes by Jan. 1, 2026.
• Real-time approvals: 80% of electronic PA requests with required documentation should be answered in real-time by 2027.
• Standardize electronic PA submissions using Fast Healthcare Interoperability Resources (FHIR)-based APIs, operational by Jan. 1, 2027.

While MGMA welcomes this pledge, it is important to acknowledge that it remains voluntary and lacks accountability or reporting mechanisms. MGMA previously joined a Consensus Statement on Improving the Prior
Authorization Process⁸ in 2018 with provider groups and health plans that outlined similar principles, yet in the subsequent years, PA continued to be the number one cited regulatory burden for medical group practices.

What Else is New?

WISeR (Wasteful and Inappropriate Service Reduction) Model

The WISeR Model, which will launch Jan. 1, 2026, and run through Dec. 31, 2031, requires prior authorization for 17 outpatient services that CMS associates with overuse or fraud in Traditional Medicare (e.g., knee arthroscopy, epidural steroid 24 injections, nerve stimulators, skin and tissue substitutes) and will be tested in six states, including New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Participating technology vendors will use tools such as artificial intelligence and machine learning to streamline PA, though licensed clinicians must make final determinations. 

MGMA and other groups voiced concern that the model will increase PA burdens, delay patient care, and contradict the administration’s stated goal of reducing regulatory requirements.⁹ CMS defends the model as narrowly tailored to high-risk, high-waste services, protecting patients without creating unnecessary barriers. However, CMS may lack statutory authority for PA in Traditional Medicare, the model could create improper incentives for vendors to deny care and possibly undermine fairness and patient access. MGMA calls for greater transparency, stronger oversight, and a focus on streamlining or reducing existing PA requirements rather than adding new ones, like the WISeR model.

MGMA Takeaways

CMS’ Interoperability and Prior Authorization Final Rule serves as the springboard for policies that ensure faster decisions, standardized data exchange, and public accountability. The Seniors’ Act would codify these gains into statute and push toward real-time prior authorization for MA plans. For the next 12–24 months, medical group practices will focus on connecting to payer APIs, tightening workflows around new decision deadlines, and leveraging emerging transparency to drive better payer performance.

Even as CMS advances new rules and the industry makes pledges, real relief will depend on payers reducing the overall volume of prior authorization, reducing the turnaround time for PA requests, standardizing criteria, and automating what remains. This relief is especially critical for small and independent medical group practices that lack resources to hire dedicated personnel to manage the growing volume of requests, which will hopefully be reduced as these measures are implemented. Gains in prior authorization reform in MA will also be weighed against proposals to increase its use in Traditional Medicare.

Medical group practices can help MGMA advance advocacy strategies by joining the MGMA Policy Advisory Network to help MGMA inform policymakers of the real-life impact regulations have on practices, and by engaging through MGMA’s Contact Congress portal (www.mgma.com/contact-congress) to urge congressional leaders to support the Seniors’ Act, along with other key legislation.

Follow this issue and others in the Washington Connection email newsletter. We encourage members who have questions to contact us at 202.293.3450 or govaff@mgma.org.

Notes:

1. Levinson DR. “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials.” HHS-OIG. September 2018. Available from: http://bit.ly/46NdW99
2. MGMA Government Affairs staff. MGMA Annual Regulatory Burden Report - 2023. Available from: https://www.mgma.com/regburden23
3. MGMA Government Affairs staff. “2024 Medicare Advantage/Part D Proposed Rule Regulatory Brief.” May 2023. Available from:http://bit.ly/4nf6oC2
4. MGMA Government Affairs staff. “MGMA statement on CMS’ Interoperability and Prior Authorization final rule.” MGMA. Jan. 17, 2024. Available from: https://www.mgma.com/pa-011724
5. MGMA Government Affairs staff. “MGMA comments on interoperability and prior authorization proposed rule.” MGMA. March 13, 2023. Available from: https://www.mgma.com/031323-interop-pa
6. MGMA Government Affairs staff. “MGMA Coalition Partners Statement on Prior Authorization Reform.” MGMA. June 28, 2025. Available from: https://www.mgma.com/pa-062825
7. MGMA Government Affairs staff. “MGMA Statement on Health Plans’ Commitment to Simplify Prior Authorization.” MGMA. June 23, 2025. Available from: https://www.mgma.com/pa-pledge25
8. “Consensus Statement on Improving the Prior Authorization Process.” 2018. Available from: https://bit.ly/4prAzaF
9. MGMA Government Affairs staff. “MGMA Opposes WISeR Model Implementation in Medicare Fee-for-Service.” MGMA. Aug. 12, 2025. Available from: https://www.mgma.com/wiser081225