Prior authorization (PA) remains one of the most debated aspects of modern health care. Intended to ensure that treatments and services are medically necessary and cost-effective, the process is often criticized for causing administrative burdens, delaying care, and straining the relationships between health care providers and payers. In 2024, PA became a focal point for both regulatory action and technological innovation.
The Centers for Medicare and Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Rule (CMS-0057-F) in January 2024, signaling a major shift in how PA will function in the future. The rule, designed to reduce delays and improve transparency, mandate faster decision-making, streamline data sharing, and enhance interoperability, specifying that certain provisions must be in effect by January 2026. In addition, 13 state-level bills addressing PA reform were enacted throughout 2024, reinforcing the widespread momentum to overhaul the system. These changes reflect an industry-wide recognition of the need to reduce barriers to care while addressing inefficiencies.
With these developments as a backdrop, 2025 is shaping up to be a transformative year for PA. Here are the key trends expected to influence its evolution.
Regulatory Compliance as a Catalyst for Change
As previously mentioned, CMS finalized its Interoperability and Prior Authorization Rule in 2024, mandating faster decision times, greater transparency, and enhanced data sharing by January 2026. In 2025, health plans will need to adopt new technologies that align with these provisions. The result will likely be an increase in interoperability between payers and providers, and reduce delays in care delivery.
The regulatory changes introduced by CMS and individual states are not just bureaucratic hurdles—they are an opportunity to transform PA into a more collaborative, efficient, and patient-focused process. Rather than viewing compliance as a challenge, leading health care organizations see it as a catalyst for broader innovation. By investing in intelligent solutions, they can transform PA from a transactional process into a strategic tool that supports value-based care.
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About the Author: Brian Covino, M.D., FAAOS
