Federal Prior Auth Rules Slow Down Practices

Prior authorization decisions came under a federal clock on Jan. 1. Eight months in, 44 percent of medical group leaders say the process is slower than it was in 2025, and just 7 percent say it is faster. This disparity highlights ongoing challenges in streamlining prior authorization processes despite regulatory efforts.

The numbers come from a Sept. 1 MGMA Stat poll of 178 medical group leaders. Another 40 percent said turnaround is about the same as last year, and 9 percent were unsure. The poll shows the mixed experiences of medical groups in adapting to the new federal requirements.

The clock covers the smallest part of the job

The requirement they were measuring against took effect at the start of the year under CMS-0057-F. Medicare Advantage organizations and several Medicaid and CHIP payers generally must return decisions on non-drug items and services within 72 hours for expedited requests and seven calendar days for standard requests. Payers also must give a specific reason when they deny. This rule aims to reduce delays in patient care by setting clear timelines for payer responses.

Practices reporting slower turnaround told MGMA the holdups were status checks, peer-to-peer reviews, and heavier documentation demands. None of those sit inside the decision window the rule regulates. These administrative tasks remain significant pain points for medical groups, despite the regulated decision timelines.

That is the gap. Before a payer’s review period starts, staff have to determine whether an authorization is required at all, find the right submission channel, and assemble supporting documentation. After the decision lands, they field requests for more information, denials, and appeals. A shorter deadline on the middle step does not shrink the work on either side of it. This highlights the need for a more holistic approach to reducing prior authorization burdens.

The trend line was already pointed the wrong way. MGMA’s 2026 Regulatory Burden Report found 90 percent of practices saying prior authorization burden had grown over the previous 12 months, with Medicare Advantage ranked the most burdensome payer type to get an authorization through. This growth in burden has been a persistent issue, affecting both administrative efficiency and patient care.

Two kinds of faster

The staff cost shows up in the same places every time. A March poll found 61 percent of practices had staff logging into seven or more payer portals a week, with eligibility and prior authorization among the main reasons. This frequent portal usage adds to the administrative workload, diverting resources from patient care.

The small group reporting improvement did not all get there the same way. Some pointed to payer moves: fewer services requiring authorization, broader electronic submission, and gold carding. Others had bought the improvement themselves by adding an authorization specialist, redesigning workflows, or buying new technology. These varied approaches reflect the diversity in strategies to address prior authorization challenges.

That distinction matters at budget time. The second kind gets patients an answer sooner while the practice absorbs the cost, which is a service win and an operating loss. Practices must weigh the benefits of faster patient care against the financial impact of additional resources.

Historically, prior authorization processes have been criticized for causing delays in patient care, with some arguing that the administrative burden outweighs the benefits. Wikipedia provides a detailed overview of the prior authorization process and its impact on healthcare delivery. These criticisms show the need for ongoing reforms to balance cost control with patient access to care.

Build the baseline now

Practices that cannot say which payers are getting worse are in a weak position to argue about it. At minimum, track payer and plan, submission and decision dates, whether the request was standard or expedited, requests for additional information, status checks, peer-to-peer reviews, denials, appeals, and the final resolution date. Full tracking is essential for identifying trends and advocating for improvements.

CMS now requires affected payers to publicly report aggregate prior authorization metrics each year, including approval and denial rates, approvals after appeal, and the average time between submission and decision. Practice-level data is what lets a leader check that reporting against what the front office actually experienced. This transparency helps hold payers accountable and ensures accuracy in reported metrics.

The next federal date is Jan. 1, 2027, when affected payers must stand up Prior Authorization APIs meant to move requests, decisions, and documentation electronically. MGMA has published a readiness resource on the payer API technical requirements, and the Physicians Practice prior authorization handbook walks through what the rule does and does not require of payers, what to ask a vendor, and what to put in a contract before the deadline. These resources are critical for ensuring compliance and leveraging new technologies effectively.

The APIs will take some of the manual work out of submission. Nothing in them requires a payer to ask for less documentation, skip the peer-to-peer, or stop sending a request back for more information, which is where this year’s poll says the time is actually going. While APIs offer efficiency gains, they do not address all the underlying issues contributing to delays in prior authorization processes.