Prior Authorization in 2026 

Prior authorization (PA) is a healthcare utilization management tool, requiring providers to request and receive authorization for a prescribed drug or service before coverage will be provided. It aims to control healthcare costs and promote appropriate use of care, but concerns have been raised that the process may create barriers to or delay access to needed care and burdens providers.  

Earlier this month, Centers for Medicare and Medicaid Services (CMS) administrator, Dr. Mehmet Oz, published a blog post outlining the negative impacts of prior authorization and reiterating CMS’ commitment, announced in June 2025, to improving the PA process.  At that time insurance industry leaders pledged to improve the PA process by way of six reforms: 

• • Standardizing electronic prior authorization submissions using electronic interfaces; 

• • Reducing the volume of medical services subject to prior authorization by 2026; 

• • Honoring existing authorizations during insurance transitions; 

• • Enhancing transparency and communication around authorization decisions and appeals; 

• • Expanding real-time responses for most requests by 2027; 

• • Ensuring medical professionals review all clinical denials. 

According to this month’s CMS post, leading carriers have announced that they have eliminated 11% of PAs for services since June 2025. CMS also announced the next stage of improvements for the PA system: aligning electronic prior authorization (ePA) across stakeholders to ensure seamless data exchange and interoperable end-to-end workflows across the PA system. The goal of this stage is to continue to bring the system into compliance with 2024 CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).  

Carriers are now required to meet response deadlines under the rule for all PA requests for services. CMS released proposed changes to the rule last month that would implement similar requirements for prescription drug PA requests as well as increase transparency requirements and update ePA standards. The goal is to bring together stakeholders across the prior authorization system, including Electronic Health Record (EHR) vendors, clinicians, and health plans to enact a more effective ePA system, predicting savings of $15 billion over ten years.  

States and carriers are also stepping up to take action on prior authorization. States across the country are assessing the impact of prior authorization on their residents and healthcare systems, and some are taking action. In 2024, the American Medical Association released a comprehensive matrix of state activity related to prior authorization, addressing standards including: 

• • ePA 

• • Response times 

• • Durations of approvals 

• • Data reporting and transparency 

• • Clinical criteria 

• • Reviewer qualifications 

• • Gold carding 

Just this month, UnitedHealthcare announced that it is eliminating prior authorization requirements for 30% of healthcare services. 

Jointly, these efforts are chipping away at the negative impact that PA can have on access to care, treatment adherence, and clinical outcomes, and the burnout and increased financial costs that can face patients and providers alike. Each initiative is an important step forward, but ultimately system-wide coordination and investment is needed for an improved system in the long run.  

For more information on the expertise PCG can offer in this area, please reach out to lkaplanhowe@pcgus.com.