December 9, 2025 • 37 mins
Kathy Roe, Managing Attorney, Health Law Consultancy, speaks with Dorothy DeAngelis, Senior Managing Director, Ankura Consulting, and Richelle Marting, Attorney, Marting Law, about the latest trends and developments related to prior authorization, from both the payer and provider angles. They discuss what prior authorization is and why it engenders scrutiny, approaches to easing prior authorization’s administrative burden, the responsible use of artificial intelligence, the impact of the new WISeR Model, and what to expect in 2026. From AHLA’s Payers, Plans, and Managed Care Practice Group.
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Learn more about AHLA’s January 8, 2026 webinar on prior authorization: https://educate.americanhealthlaw.org/local/catalog/view/product.php?productid=1705
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:04):
This episode of AHLA Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmerican Health Law.org.
SPEAKER_02 (00:17):
Greetings, everybody.
Thank you for joining us todayfor AHLA's Speaking of Health
Law podcast.
Today's episode is entitledPrior Authorization, Payer and
Provider Perspectives as 2025comes to a close.
(00:38):
I am Kathy Rowe.
I am the managing attorney atthe health law consultancy in
Chicago.
It's a boutique health law firmfocused on regulatory
contracting and counseling inthe health care space.
And I am also the chair of thePayers of Lands and Managed Care
(01:00):
Practice Group.
And that's the practice groupthat is bringing you today's
podcast.
I'm joined by two guests, andI'd like them to have them
introduce themselves to you.
Dorothy?
SPEAKER_01 (01:14):
Yes, hi everyone.
I'm Dorothy DeAngelis, SeniorManaging Director with Anchara
Consulting.
I head our healthcare and lifesciences industry group here at
Anchara, and my focus iscompliance, disputes,
investigations, and spending alot of time in prior
authorization in particular.
SPEAKER_03 (01:38):
Hi, thank you for having me.
My name is Rochelle Martin.
I'm an attorney in the KansasCity area.
I work with providers, bothprofessionals and facilities
around the country on managedcare contracting.
My background is in healthinformation management.
I'm an RHIA and a certifiedcoder.
So a lot of the lens throughwhich I approach prior
(02:00):
authorizations are from acontracting compliance, a
regulatory compliance, and thensort of a revenue perspective, a
revenue cycle lens.
SPEAKER_02 (02:12):
All right.
It sounds like we've got ourpayer and our provider voices
for today.
So let me start off from adefinitional perspective to make
sure we're all on the same page.
And when we're talking aboutprior authorization, we're
talking about a utilizationmanagement process carried out
(02:37):
by a payer to assess the medicalnecessity and the medical
appropriateness of a health careservice, item or drug prior to
the delivery of the health careservice item or drug.
So that's our definition.
(02:59):
And sometimes there's differenttakes on the definition.
But one point that I would liketo raise to kick us off is in
talking about what prior auth isabout.
And I may say prior authors orwe may say PA.
In all instances, what we'retalking about is prior
(03:21):
authorization.
But sometimes folks say thatprior authorization is not a
guarantee of payment.
So Dorothy, is a prior authapproval?
Is it a guarantee of payment orsomething else?
SPEAKER_01 (03:37):
Yeah, it's a good question, Kathy.
Basically, you know, from myperspective, prior auth really,
as you said, I mean, it makessure that the recommended
service item or supply ismedically necessary and
appropriate for the patient orthe member.
And there may be, however, theremay be other issues that you
(03:57):
know arise with the uh claim,you know, after the fact or even
as the prior office beingreviewed, things like
eligibility, networks, um,coding errors, and the like.
So that's why it really doesn'tguarantee payment.
There's sort of two differentthings.
I view PA, however, as a gatingissue to obtaining that payment
(04:21):
often if one is to be applied,uh, but it certainly, in my
view, is not necessarily aguarantee.
SPEAKER_02 (04:29):
Would you agree with that, Rochelle?
SPEAKER_03 (04:31):
Yeah, I love this question.
And I like the foundational umconcept of starting with the
definition because talking toAHLA and folks interested in
health law, we know it depends.
It can depend on the definitionin your contract under state
law, under federal law, underthe individual benefit plan.
(04:53):
And so we have this kind ofoverarching concept of the
nuances can be so specific toeach individual plan and each
individual claim or service,even.
But I always say, I also say itdepends on whether it's a
guarantee of payment.
Um, for example, there's there'slanguage in a Medicare Advantage
manual from CMS that priorauthorizations are advanced
(05:14):
approval that payment will bemade, and that payment can't
later be denied once priorauthorization is obtained, based
on medical necessity.
So I agree with Dorothy.
It is a it's a gateway topayment in overcoming one of the
initial hurdles to approval andto payment, which is whether
we're providing a coveredservice.
(05:36):
It's reasonable, it's necessary,it's appropriate for the
patient, and prior authorizationsort of accomplishes or
greenlights that perspective.
Of course, then you have toproperly code and bill and
present the claim, and thepatient has to be an eligible
member for that data service,and you overcome those
challenges, but it it achieves asignificant hurdle towards the
(06:00):
payment of that service.
SPEAKER_02 (06:03):
Okay, I think we now have a good grounding as to what
prioroth is about and how it'scommon across different benefit
programs, but may varydefinitionally in terms of the
nuances.
(06:24):
But I think it's fair to saywhether you sit on the provider
side, the payer side, thepatient side, hire off is
something that in the lastseveral years has been an object
of critique.
Do either of you want to speakto that critique again?
(06:46):
How the industry may beresponding?
SPEAKER_01 (06:51):
Yeah, I I will be happy to start that um
discussion, but uh, you know, ithas been heavily scrutinized,
Kathy.
You're absolutely right.
Um, in terms of why that is thecase, um, you know, in my view,
it's because uh a request forprior authorization is in
Medicare Advantage a coverage ororganization determination,
(07:14):
really.
Um, and that has an impact onpotential for member harm.
You know, if something is beingdelayed from a clinical
perspective, um that can causetreatment issues, uh especially
if if the prior auth is not doneappropriately.
It can also cause later down theline a financial impact or
financial harm if that was, as Isaid, a gating issue to
(07:37):
obtaining payment down the lineand it doesn't occur, and the
service is an expensive one, youknow, some sort of inpatient or
even hospital outpatientprocedure, uh, that has
significant financial impact aswell.
And you know, lastly, I wouldsay it's it's scrutinized
because I think it's deeplypersonal because so many of us,
whether it's you know, those ofus on this call or people, you
(07:59):
know, clients that we deal with,or even frankly members of
Congress, I think we all um dealwith prior authorization in one
way or another and have perhapsyou know had one take longer
than we would like, or you know,it just can cause a lot of
frustration.
So it definitely is a bit of alightning rod issue in my mind.
SPEAKER_03 (08:21):
I think from the patient perspective and
provider, healthcare providersthat want to advocate for their
patients, there's a perceptionof prior authorization being a
roadblock or a delay in care ora denial of care.
Even though prior authorizationsand utilization management is
not intended to override thephysician or the professional's
(08:42):
judgment making recommendationsand treatment decisions for
their patients, the reality isthat when a prior authorization
is denied, that is a tremendousdeterrent for proceeding with
that care because of thepotential financial implications
to the patient.
So hearing about patient accessand delayed access seems to be
(09:04):
one of the biggest reasons priorauthorization processes seem to
be scrutinized.
The provider community, and Iuse provider broadly for
healthcare professionals as wellas facilities that work with
third-party payers andutilization management and
review entities, they theystruggle with the guidelines or
(09:27):
the parameters and whether theyagree or disagree that those
reflect current industrystandards, the qualifications of
the reviewers that they talkwith through the prior
authorization process, and howlong it can take from start to
finish to get what hopefullywill be a green light at the end
of the day that the patient canreceive the care they need.
(09:48):
And then on the back end, Ithink there is a perception that
if prior authorization wasdenied, while approval is not a
guarantee of payment, perceptionthat a denial is merely a
guarantee that the service willnot be paid and create some
challenges on the back end forproviders delivering care to
those members.
SPEAKER_02 (10:11):
So in your remarks, Rochelle, you are really
starting to get at some of theareas of administrative burden.
And do either of you want tospeak to some of the legislative
(10:31):
or regulatory or even thevoluntary commitments that
payers have made this summer andwhat they're going after and the
prospect of those commitments orlaws making a change for the
better and prior off in itsperception.
SPEAKER_01 (10:53):
Yeah, sure.
Um I can certainly start that.
I I think one of the latest orlargest developments, um, there
are a number of them, but onefrom a legislative perspective
was uh CMS final rule oninteroperability and the one
that requires the implementationof FIRE-based APIs so that
(11:13):
providers can submit requests uhfrom their uh EHR, uh EMR
systems.
And that particular legislationdid a number of things in terms
of increasing access that way.
It also reduced turnaroundtimes, which is one of the pain
points that was mentioned, Ithink, by both of us, and um
(11:34):
taking those two 72 hours for uhan urgent request and seven days
for standard.
And then there are datareporting uh requirements for
transparency purposes, and theum turnaround times and
reporting requirements go intoeffect on 101, 26, while the
(11:54):
APIs go into effect in 2027.
Um I think in addition to that,yes, you are right, Kathy.
You know, there was the uhannouncement later or earlier
this year in the summer, uh,whereby you know the president
and several large payersannounced that they would be um
you know trying to reduce orcommitting to take a pledge to
(12:15):
reduce this burden.
Um we have seen some of thelarge payers um taking off the
plate the number of servicesthat even require PA.
Um, and that that has been uhone of the focal areas.
And then the third piece that Ithink uh it's being utilized to
try to admit, you know, at leasttake away some of the
administrative burden off ofwhat used to be a very manual
(12:38):
process is probably artificialintelligence or AI.
And yeah, that's being used byboth payers and providers, um
whether it's to automaticallysubmit an appeal if the request
was denied by providers or bypayers to automate certain
aspects of prior auth.
Of course, not the portion thatrequires uh, you know, a medical
(13:00):
director review and sign-off,but at least the portion that
would cut down on some of thereally um tedious manual
searches that that occur.
SPEAKER_02 (13:12):
How about you, Rochelle?
Do you want to add to that?
Because one of the things Idon't think I mentioned, or I'll
just emphasize again, is thatwe've had legislative activity
or I shouldn't say legislative,we've had legislative activity
at the states and severalstates, hitting the commercial
(13:36):
and in some cases the Medicaidmarket.
We've had regulatory action atthe federal level.
So, what's your your view fromthe provider standpoint?
SPEAKER_03 (13:56):
Yeah, I look at announcements uh with
third-party payers reducingprior authorization volume uh
with a little bit of skepticism.
It solves a tremendous umroadblock for access, and it's
helping patients get the carethat they need for services
faster.
And then the providerperspective is a concern that
(14:19):
absent that prior authorizationthat shows the plan at least
gave their stamp of approvalthat this was medically
reasonable and necessary forthat patient for that
circumstance at that time, thatthe providers will deliver the
care and still nonethelessreceive a denial on the back end
now that they've they've giventhe care, the expenses have gone
(14:41):
out.
So there's a maybe healthy levelof skepticism to be determined
as those processes play out.
Are they achieving the goals ofimproved access and still not
putting the healthcare providercommunity at a financial
disadvantage?
Um, because they they do like topoint to that prior
authorization as a some sort ofprotection on the back end that
(15:04):
they have a decent chance ofgetting paid assuming the claim
is presented properly.
But Dorothy mentions um AI as ahot topic to potentially reduce
administrative burden.
And I think there's so many,there's opportunities and so
many considerations in the worldof AI with prior authorization.
We've seen headlines and andeven litigation scrutinizing
(15:30):
plans that maybe began using AIas a tool to automate and
expedite approvals, which is afantastic use of AI to get those
prior authorizations through asquickly as possible, but
scrutiny that it was used toexpedite denials as well.
And you can see headlines of aphysician who affixed a
(15:52):
signature, you know, thousandsand thousands of times over the
course of the month.
So there's that balance of usingit for the right purposes to
expedite, well, as Georgie said,um, reserving the clinical
decision if there could bepotentially an adverse decision.
And we've seen that balance insome rulemaking in 2024, 25, I
(16:16):
believe, that didn't getfinalized for Medicare Advantage
plans.
Um, because I think there isstill uncertainty on how to
effectively and appropriatelybalance those pros and cons in
the use of AI.
And on the provider side, um, AIis maybe more in an infancy
stage in terms of appealingprior authorization denials than
(16:39):
I think it is on the payer side,where there seems to be more
sophisticated and systematic umways to leverage those tools.
And it feels a little bitpiecemeal on the provider side
still, on how we can quickly andefficiently and effectively
provide the information to plansto get to that approval um uh
(17:01):
more expediently.
SPEAKER_02 (17:04):
I think there is definitely a literacy issue, for
lack of a better word, in termsof understanding exactly how and
where in the prior authorizationprocess A AI is being used.
People oftentimes speak about itso generally that it raises a
(17:28):
prospective concern.
But I think its usage issomething to watch, not only in
the real world, but also withthe administration, because if
anybody took a look at therequest for information that the
Office of Science and Technologypolicy put out about six weeks
(17:50):
ago, it was in asking forproposed reforms to regulation
of artificial intelligence.
This was one of the proposedaction items in the AI action
plan issued by the White Housein July.
The beginning of that RFI,before it gets to the questions
(18:12):
to prompt the public, it laysout various what are
characterizes faulty assumptionsthat there oftentimes is an
inclination to go towardsregulating artificial
intelligence akin to how wewould regulate humans.
And they actually talk abouthuman oversight and human
(18:36):
decision making, and then theygo on and talk about how
healthcare is a sector that isripe for AI.
So I think you will hear atleast some proponents who who
would say, but geez, if you canadequately train in AI, mightn't
it be a more effective tool interms of making both approvals
(18:59):
and denials?
I think we're we're a ways awayfrom a cultural acceptance uh of
that, but I certainly thinkthere is some corner of our
country that is thinking in thatregard, maybe beyond just
corners within payers or vendorsthat serve payers.
SPEAKER_03 (19:24):
But like it or love it, it could solve some of the
concerns that providers haveabout inconsistencies in
decisions and and maybe helpalleviate or bridge some of that
gap.
SPEAKER_01 (19:37):
Yeah, that's a really good point, uh, Rochelle
and Kathy, all good points madeby you as well.
I I think what we're talkingabout here are a couple of
things.
One is the responsible use of AIin this space, um, and that is
to be determined in terms ofwhat the guardrails are going to
be.
Um, as Rochelle said, there weresome really important, I think,
points that would have been inthat regulation that did not
(19:59):
get.
Finalized by CMS.
Hopefully, you know, that will.
And then the other thing is thepoint of adoption and the
literacy of it, as you pointout, Kathy.
I mean, you know, I think it'simportant to meet providers or
payers where they are withregard to that adoption and then
kind of take them along thatjourney in terms in terms of
(20:20):
what is possible in theresponsible use of AI.
And that's something that I dealwith a lot in my practice
because, you know, you both saidit very well.
Not everyone is up to speed onthis, not everyone trusts it.
But there are uses that wouldhelp in many regards, whether
it's consistency or speed,reduction of manual processes
(20:44):
and the like.
But it's just finding wherethose guardrails really should
should exist.
SPEAKER_03 (20:49):
Well, Kathy, you started this discussion with the
definition of priorauthorization.
What's the definition ofartificial intelligence where
you can even begin to regulateor decide how it's going to be
used responsibly in the space ofsomething so important as prior
authorization and access tocare?
SPEAKER_02 (21:08):
That's such a wonderful point about the
definitional inconsistency ofartificial intelligence.
You have some narrow definitionsand broad definitions.
And even when they're close,there's always like a word or
two different between states ordifferent organizations.
(21:31):
And I don't know when we'regoing to get sort of that
driving influence here in theUnited States that kind of has
us heading all towards a singledefinition.
It's kind of like the definitionof specially drug or specially
product in the pharmacy benefitsspace.
(21:53):
But talking about AI makes mewant to ask you both.
Have one of you talk about thewiser model that is set to
launch at the beginning of nextyear?
And that's CAP W, Cap I, Cap S,lowercase E, Cap R model.
(22:14):
It's out of CMMI, that's anacronym.
But what it is, and there's beena lot of talk about it,
certainly at the administrationas well as in Congress.
SPEAKER_01 (22:28):
Yeah, this was uh quite an interesting uh what I
would almost call curveball uhyou know that was that was
thrown.
Um so what it is, uh well justto level set again, prior auth
is a utilization managementtool, and just the concept of
utilization management generallyspeaking is more common in the
managed care context.
(22:49):
Um the Wiser program is set upto pilot uh for original
Medicare, which is more of a feefor service, obviously a fee for
service program.
And so traditionally, prior authwas used in original Medicare in
a very limited set ofsituations.
Examples of which would becertain uh hospital outpatient
(23:09):
department services, some DME,uh, some non-emergency transport
requests, and regardless, thesewere handled by the MACs, the
Medicare Administrativecontractors.
What Wiser is seeking to do iswork with private contractors,
technology contractors, uh thatwould use, they'll use AI tools
(23:30):
and review PAs for serviceswhere it's thought that there's
a high potential for fraud,things such as skin substitutes,
knee arthroscopy for arthritis,osteoarthritis, or those are
good examples.
This causes some concern and hascaused some scrutiny because,
again, now we're talking aboutblurring the lines between a
(23:52):
fee-for-service program and amanaged care program.
We're also talking aboutintroducing more prior auth in
original Medicare, which couldintroduce delays again for
physicians and patients.
And then really, I think thelargest area of scrutiny is the
model itself, whereby thesecontractors would operate on a
(24:14):
recovery basis, meaning thatthey would receive a percentage
of savings.
And that is something that wehaven't seen, or you know, would
certainly frown upon, at leastfrom the managed care
perspective.
Um, and then the last piece isAI again, right?
So we've just talked about howthere's no set definition, we
(24:36):
don't have a mandated frameworkfor oversight, but we have a lot
of information for how CMSwanted Medicare Advantage
organizations to view AI and useit in prior auth.
And one of the couple of thoseconsiderations were you know
such that you would still takeinto account individual facts
and circumstances of the case,not make big sweeping decisions,
(24:58):
and that also there would be nodiscrimination or that bias and
things of that nature that cancreep into these models would be
carefully reviewed and certainlynot take place.
So those are some of the thingsthat that I would point out uh
with regard to Wiser.
SPEAKER_03 (25:18):
Yeah, thank you, Kathy.
I I am not in one of the stateswhere Wiser will be rolled out
initially, but we are watchingcarefully for how that how that
program is impacted.
And Dorothy, you use the wordcurveball, and that was my
reaction when the Wiser modelwas announced because it came on
the heels of proposed rules thatwould really tighten the way AI
(25:41):
is used in prior authorizationfor Medicare Advantaged Plan.
And those those rules or thoseproposals were sort of tabled.
We had a change inadministration while that
proposed rule was was with theagency.
And then this model almostseemed to conflict or just take
a hard right um uh in the sensethat it just hived it from the
(26:06):
approach or the tone of theproposed rule for Medicare
advantage and now whattraditional wood medicare would
be doing.
So a little bit of of kind ofriplash on on the policy
perspective or the approach.
And I think that's the questionpatients and providers want to
see with this wiser model,especially given Dorothy that
your comment that thecontractors have a financial
(26:30):
incentive to deny.
And that's different from theRAC model, where a contingency
fee was was such an uproar adecade and a half ago when that
program began.
But that was payment on the backend where this could be access
on the front end.
And so it really will beinteresting to see how the the
(26:50):
industry and patients respond tothat.
But you also um mentioned,Dorothy, areas where there's a
high likelihood of a fraud oroverpayment or a lot of money at
stake, and you use skinsubstitutes as an example.
And I've been watching thatreally closely because I defend
a lot of providers in mypractice against traditional
(27:11):
Medicare audits and Mac auditsand UPIC audits and rack audits
and skin substitutes are a topicthat's been um highly contested
over the last few years.
And what I like about the wisermodel in that particular area is
it gives me provide growthproviders peace of mind up
front.
(27:31):
Before I purchase this productand spend a lot of money that I
will not get feedback, it's notjust my professional time I
would lose if I have to pay backfor this actual expense.
Having the prior authorizationon the front end, I think in
certain areas could could reallybe beneficial to both providers
and patients.
SPEAKER_01 (27:51):
Yeah, I I think that's a fair, fair point, uh
Rochelle.
And um some of the things here,I mean, with with regard to
utilization management, I mean,I think that's always been the
case that um anything, and I usethe drug example.
I do a lot of work, as saysKathy, in the Part D arena and
(28:11):
um in the drug claim arena.
And you know, whether or not thedrug carries a high risk with it
is always a component of whetheryou're going to apply prior
authorization.
Um, so from that perspective,you know, I definitely
understand where this policy iscoming from, and I understand it
from the perspective of wantingto cut down fraud, waste, and
abuse.
(28:32):
I think again, the componentthat is most concerning or
raises some eyebrows is thatrecovery uh element and doing
that on the front end where youcould really be incentivized to
um you know cut off someone'saccess.
So I think all eyes are going tobe watching how that really
plays out.
SPEAKER_02 (28:53):
It'll be interesting to see what reporting comes out
on this model and at what pace,sort of akin to the transparency
that's being mandated by otherCMS regulated uh plans and
whether Medicare fee for serviceI'll say measures up to that
(29:16):
level of transparency for thisprogram.
SPEAKER_01 (29:20):
Exactly.
And you know, one other thingthat's kind of interesting is
that the uh physician feeschedule final regulation rental
rule came out and it containedsome interesting um uh
arrangements with regard tofinancials around skin
substitutes.
So there again, you you've gotthis weird policy juxtaposition
(29:41):
of coming up with a potentialsolution to reduce those prices
uh that way.
And then my I guess my questionwould be: do you really still
need that prior auth on thefront end?
Uh I guess that all remains tobe seen and we'll have to work
through once these things getimplemented.
SPEAKER_02 (30:00):
Do either of you think the wiser model will have
anything to say about theapplication of AI, harking back
to earlier earlier in ourconversation relative to its
application in MA or in otherlines of business?
(30:20):
Rochelle says she's watching themodel closely.
Should others be watching itclosely as well and with an eye
on what?
SPEAKER_03 (30:30):
Yeah, I I I again I kind of go back to the RAC
program when that was a new andrevolutionary concept and um
hotly debated because of thecontingency fees in that
program.
I think we'll see an evolutioncome out, and that's why it's
being piloted in a few areas,and there will be an evolution
of policy on whether and how andto what extent AI is used in the
(30:53):
guardrails and the protections.
And we will probably seereporting on prior authorization
requests and approvals anddenials.
Uh, and I think that's what weshould be watching to see how
that program may evolve andwhether it's likely to extend to
other geographic areas.
SPEAKER_01 (31:10):
Yeah, another is true, and another interesting
place that we can keep our eyespeeled is in the uh information
that gets released each year forMAOs, Medicare Advantage
organizations to put their uhsubmit their bids for payment.
So theoretically, uh these theseif the Wiser model moves forward
(31:33):
and it does bring down, let'ssay, uh the rising medical cost
trend, which is very significantand a significant issue right
now.
If it does that in the states inwhich it's being implemented, uh
we should see that in the USPCCs, the US per capita costs
that are derived from fee forservice Medicare utilization,
(31:55):
and then that's given to theMedicare Advantage organizations
for them to proxy their bids.
Theoretically, what should startto happen is those costs come
down, and then the plans wouldbe in those states, you know,
have a lower bid target or lowercost target to go against with
regard to their bid.
(32:16):
So we could, I suppose, comparewhether you know it's in place
in those states versus othersand see what plays out in the US
PCCs.
It would be a nice way toanalyze how this is actually
working once we actually startto see results.
SPEAKER_02 (32:34):
So I think it's about time for us to wrap up.
So we've talked about where weare with PA as 2025 comes to a
close.
I would love to hear from eachof you where should folks be
focusing their eyes for PA as2026 launches.
SPEAKER_03 (32:56):
The wiser model is first and foremost what
everybody has their eyes on intraditional Medicare and how
that how that program plays outin the 2026.
We haven't talked a lot aboutstate law policy, and that is
something in our area that weare seeing an increase in state
laws taking initiative toimplement various prior
(33:18):
authorization policies.
Often those are even morestringent than some of the
federal proposed rules, whichcan be great for patient
protections and consumers andconstituents in the state, but
also create complexities forplans that or payers, I should
say, that have plans governed bydifferent bodies of law on how
(33:40):
to effectively administerdifferent rules, as it is
challenging on the provider sideto figure out those processes
and those rules in thispatchwork of state law and
federal law.
And that's just in the priorauthorization space.
We also, as we've kind of beentalking about over the last um
(34:00):
over the last hour here, the thedeveloping framework and
patchwork of AI rules as itapplies in the healthcare space.
Those I think are going to betrends into 2026 to see how
federal policy is developing andevolving, and then how state law
is either following suit ormaybe straying from what federal
(34:21):
policy is doing.
SPEAKER_01 (34:24):
Yeah, I think those are all good things to watch.
I agree, I all eyes on Wiser,and um certainly I think the
Democrats in Congress arealready taking aim at it.
There's certainly a lot ofpushback on it already before it
even starts.
Uh, I agree, you know, the AIframework and whether you know
there's more to come on thatfrom a legislative or even
(34:47):
policy perspective.
Uh, and then um the other thingI would say is just staying
vigilant generally, and thencertainly whether you're a payer
or a provider, it's knowing yourdata, knowing what's happening
to you, and getting control overit, understanding you know what
your denial rates really are andyou know what types of services
(35:08):
and what the rules are so thatyou can start to demystify it a
little bit, regardless of whathappens, you know, on the
legislative or policy landscape.
I think there's still a lot ofjust our operational and data
analysis work there that can bedone.
So it's kind of giving a senseof what you can do while all
this is spinning and changing.
SPEAKER_03 (35:29):
You sparked a good thought there too, Dorothy, um,
that I don't know that we'vetalked about yet, which is kind
of the evolution and rollout ofdifferent gold card, platinum
card type programs that arebecoming more popular and um
whether those are effective tobalance burden and access and
payment as well.
SPEAKER_02 (35:50):
Well, on that note, I'm gonna thank everybody for
tuning in because that gives methe opportunity to say that
Dorothy and Rochelle at least,maybe we'll have another
panelist join them.
We'll be back in early 2026 inwebinar form to talk about
(36:14):
looking ahead in 2026 for priorauthorization.
And I think talking about goldcarding and platinum carding,
given I've heard mixes mixes andfeedback on them, we will have
time to dive into that.
So let me thank everybody forjoining us today.
(36:36):
And thank the Payers Plans andManaged Care Practice Group,
which is bringing you today'spodcast episode.
Bye all.
SPEAKER_00 (36:52):
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(37:15):
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SPEAKER_02 (00:17):
Greetings, everybody.
Thank you for joining us todayfor AHLA's Speaking of Health
Law podcast.
Today's episode is entitledPrior Authorization, Payer and
Provider Perspectives as 2025comes to a close.
(00:38):
I am Kathy Rowe.
I am the managing attorney atthe health law consultancy in
Chicago.
It's a boutique health law firmfocused on regulatory
contracting and counseling inthe health care space.
And I am also the chair of thePayers of Lands and Managed Care
(01:00):
Practice Group.
And that's the practice groupthat is bringing you today's
podcast.
I'm joined by two guests, andI'd like them to have them
introduce themselves to you.
Dorothy?
SPEAKER_01 (01:14):
Yes, hi everyone.
I'm Dorothy DeAngelis, SeniorManaging Director with Anchara
Consulting.
I head our healthcare and lifesciences industry group here at
Anchara, and my focus iscompliance, disputes,
investigations, and spending alot of time in prior
authorization in particular.
SPEAKER_03 (01:38):
Hi, thank you for having me.
My name is Rochelle Martin.
I'm an attorney in the KansasCity area.
I work with providers, bothprofessionals and facilities
around the country on managedcare contracting.
My background is in healthinformation management.
I'm an RHIA and a certifiedcoder.
So a lot of the lens throughwhich I approach prior
(02:00):
authorizations are from acontracting compliance, a
regulatory compliance, and thensort of a revenue perspective, a
revenue cycle lens.
SPEAKER_02 (02:12):
All right.
It sounds like we've got ourpayer and our provider voices
for today.
So let me start off from adefinitional perspective to make
sure we're all on the same page.
And when we're talking aboutprior authorization, we're
talking about a utilizationmanagement process carried out
(02:37):
by a payer to assess the medicalnecessity and the medical
appropriateness of a health careservice, item or drug prior to
the delivery of the health careservice item or drug.
So that's our definition.
(02:59):
And sometimes there's differenttakes on the definition.
But one point that I would liketo raise to kick us off is in
talking about what prior auth isabout.
And I may say prior authors orwe may say PA.
In all instances, what we'retalking about is prior
(03:21):
authorization.
But sometimes folks say thatprior authorization is not a
guarantee of payment.
So Dorothy, is a prior authapproval?
Is it a guarantee of payment orsomething else?
SPEAKER_01 (03:37):
Yeah, it's a good question, Kathy.
Basically, you know, from myperspective, prior auth really,
as you said, I mean, it makessure that the recommended
service item or supply ismedically necessary and
appropriate for the patient orthe member.
And there may be, however, theremay be other issues that you
(03:57):
know arise with the uh claim,you know, after the fact or even
as the prior office beingreviewed, things like
eligibility, networks, um,coding errors, and the like.
So that's why it really doesn'tguarantee payment.
There's sort of two differentthings.
I view PA, however, as a gatingissue to obtaining that payment
(04:21):
often if one is to be applied,uh, but it certainly, in my
view, is not necessarily aguarantee.
SPEAKER_02 (04:29):
Would you agree with that, Rochelle?
SPEAKER_03 (04:31):
Yeah, I love this question.
And I like the foundational umconcept of starting with the
definition because talking toAHLA and folks interested in
health law, we know it depends.
It can depend on the definitionin your contract under state
law, under federal law, underthe individual benefit plan.
(04:53):
And so we have this kind ofoverarching concept of the
nuances can be so specific toeach individual plan and each
individual claim or service,even.
But I always say, I also say itdepends on whether it's a
guarantee of payment.
Um, for example, there's there'slanguage in a Medicare Advantage
manual from CMS that priorauthorizations are advanced
(05:14):
approval that payment will bemade, and that payment can't
later be denied once priorauthorization is obtained, based
on medical necessity.
So I agree with Dorothy.
It is a it's a gateway topayment in overcoming one of the
initial hurdles to approval andto payment, which is whether
we're providing a coveredservice.
(05:36):
It's reasonable, it's necessary,it's appropriate for the
patient, and prior authorizationsort of accomplishes or
greenlights that perspective.
Of course, then you have toproperly code and bill and
present the claim, and thepatient has to be an eligible
member for that data service,and you overcome those
challenges, but it it achieves asignificant hurdle towards the
(06:00):
payment of that service.
SPEAKER_02 (06:03):
Okay, I think we now have a good grounding as to what
prioroth is about and how it'scommon across different benefit
programs, but may varydefinitionally in terms of the
nuances.
(06:24):
But I think it's fair to saywhether you sit on the provider
side, the payer side, thepatient side, hire off is
something that in the lastseveral years has been an object
of critique.
Do either of you want to speakto that critique again?
(06:46):
How the industry may beresponding?
SPEAKER_01 (06:51):
Yeah, I I will be happy to start that um
discussion, but uh, you know, ithas been heavily scrutinized,
Kathy.
You're absolutely right.
Um, in terms of why that is thecase, um, you know, in my view,
it's because uh a request forprior authorization is in
Medicare Advantage a coverage ororganization determination,
(07:14):
really.
Um, and that has an impact onpotential for member harm.
You know, if something is beingdelayed from a clinical
perspective, um that can causetreatment issues, uh especially
if if the prior auth is not doneappropriately.
It can also cause later down theline a financial impact or
financial harm if that was, as Isaid, a gating issue to
(07:37):
obtaining payment down the lineand it doesn't occur, and the
service is an expensive one, youknow, some sort of inpatient or
even hospital outpatientprocedure, uh, that has
significant financial impact aswell.
And you know, lastly, I wouldsay it's it's scrutinized
because I think it's deeplypersonal because so many of us,
whether it's you know, those ofus on this call or people, you
(07:59):
know, clients that we deal with,or even frankly members of
Congress, I think we all um dealwith prior authorization in one
way or another and have perhapsyou know had one take longer
than we would like, or you know,it just can cause a lot of
frustration.
So it definitely is a bit of alightning rod issue in my mind.
SPEAKER_03 (08:21):
I think from the patient perspective and
provider, healthcare providersthat want to advocate for their
patients, there's a perceptionof prior authorization being a
roadblock or a delay in care ora denial of care.
Even though prior authorizationsand utilization management is
not intended to override thephysician or the professional's
(08:42):
judgment making recommendationsand treatment decisions for
their patients, the reality isthat when a prior authorization
is denied, that is a tremendousdeterrent for proceeding with
that care because of thepotential financial implications
to the patient.
So hearing about patient accessand delayed access seems to be
(09:04):
one of the biggest reasons priorauthorization processes seem to
be scrutinized.
The provider community, and Iuse provider broadly for
healthcare professionals as wellas facilities that work with
third-party payers andutilization management and
review entities, they theystruggle with the guidelines or
(09:27):
the parameters and whether theyagree or disagree that those
reflect current industrystandards, the qualifications of
the reviewers that they talkwith through the prior
authorization process, and howlong it can take from start to
finish to get what hopefullywill be a green light at the end
of the day that the patient canreceive the care they need.
(09:48):
And then on the back end, Ithink there is a perception that
if prior authorization wasdenied, while approval is not a
guarantee of payment, perceptionthat a denial is merely a
guarantee that the service willnot be paid and create some
challenges on the back end forproviders delivering care to
those members.
SPEAKER_02 (10:11):
So in your remarks, Rochelle, you are really
starting to get at some of theareas of administrative burden.
And do either of you want tospeak to some of the legislative
(10:31):
or regulatory or even thevoluntary commitments that
payers have made this summer andwhat they're going after and the
prospect of those commitments orlaws making a change for the
better and prior off in itsperception.
SPEAKER_01 (10:53):
Yeah, sure.
Um I can certainly start that.
I I think one of the latest orlargest developments, um, there
are a number of them, but onefrom a legislative perspective
was uh CMS final rule oninteroperability and the one
that requires the implementationof FIRE-based APIs so that
(11:13):
providers can submit requests uhfrom their uh EHR, uh EMR
systems.
And that particular legislationdid a number of things in terms
of increasing access that way.
It also reduced turnaroundtimes, which is one of the pain
points that was mentioned, Ithink, by both of us, and um
(11:34):
taking those two 72 hours for uhan urgent request and seven days
for standard.
And then there are datareporting uh requirements for
transparency purposes, and theum turnaround times and
reporting requirements go intoeffect on 101, 26, while the
(11:54):
APIs go into effect in 2027.
Um I think in addition to that,yes, you are right, Kathy.
You know, there was the uhannouncement later or earlier
this year in the summer, uh,whereby you know the president
and several large payersannounced that they would be um
you know trying to reduce orcommitting to take a pledge to
(12:15):
reduce this burden.
Um we have seen some of thelarge payers um taking off the
plate the number of servicesthat even require PA.
Um, and that that has been uhone of the focal areas.
And then the third piece that Ithink uh it's being utilized to
try to admit, you know, at leasttake away some of the
administrative burden off ofwhat used to be a very manual
(12:38):
process is probably artificialintelligence or AI.
And yeah, that's being used byboth payers and providers, um
whether it's to automaticallysubmit an appeal if the request
was denied by providers or bypayers to automate certain
aspects of prior auth.
Of course, not the portion thatrequires uh, you know, a medical
(13:00):
director review and sign-off,but at least the portion that
would cut down on some of thereally um tedious manual
searches that that occur.
SPEAKER_02 (13:12):
How about you, Rochelle?
Do you want to add to that?
Because one of the things Idon't think I mentioned, or I'll
just emphasize again, is thatwe've had legislative activity
or I shouldn't say legislative,we've had legislative activity
at the states and severalstates, hitting the commercial
(13:36):
and in some cases the Medicaidmarket.
We've had regulatory action atthe federal level.
So, what's your your view fromthe provider standpoint?
SPEAKER_03 (13:56):
Yeah, I look at announcements uh with
third-party payers reducingprior authorization volume uh
with a little bit of skepticism.
It solves a tremendous umroadblock for access, and it's
helping patients get the carethat they need for services
faster.
And then the providerperspective is a concern that
(14:19):
absent that prior authorizationthat shows the plan at least
gave their stamp of approvalthat this was medically
reasonable and necessary forthat patient for that
circumstance at that time, thatthe providers will deliver the
care and still nonethelessreceive a denial on the back end
now that they've they've giventhe care, the expenses have gone
(14:41):
out.
So there's a maybe healthy levelof skepticism to be determined
as those processes play out.
Are they achieving the goals ofimproved access and still not
putting the healthcare providercommunity at a financial
disadvantage?
Um, because they they do like topoint to that prior
authorization as a some sort ofprotection on the back end that
(15:04):
they have a decent chance ofgetting paid assuming the claim
is presented properly.
But Dorothy mentions um AI as ahot topic to potentially reduce
administrative burden.
And I think there's so many,there's opportunities and so
many considerations in the worldof AI with prior authorization.
We've seen headlines and andeven litigation scrutinizing
(15:30):
plans that maybe began using AIas a tool to automate and
expedite approvals, which is afantastic use of AI to get those
prior authorizations through asquickly as possible, but
scrutiny that it was used toexpedite denials as well.
And you can see headlines of aphysician who affixed a
(15:52):
signature, you know, thousandsand thousands of times over the
course of the month.
So there's that balance of usingit for the right purposes to
expedite, well, as Georgie said,um, reserving the clinical
decision if there could bepotentially an adverse decision.
And we've seen that balance insome rulemaking in 2024, 25, I
(16:16):
believe, that didn't getfinalized for Medicare Advantage
plans.
Um, because I think there isstill uncertainty on how to
effectively and appropriatelybalance those pros and cons in
the use of AI.
And on the provider side, um, AIis maybe more in an infancy
stage in terms of appealingprior authorization denials than
(16:39):
I think it is on the payer side,where there seems to be more
sophisticated and systematic umways to leverage those tools.
And it feels a little bitpiecemeal on the provider side
still, on how we can quickly andefficiently and effectively
provide the information to plansto get to that approval um uh
(17:01):
more expediently.
SPEAKER_02 (17:04):
I think there is definitely a literacy issue, for
lack of a better word, in termsof understanding exactly how and
where in the prior authorizationprocess A AI is being used.
People oftentimes speak about itso generally that it raises a
(17:28):
prospective concern.
But I think its usage issomething to watch, not only in
the real world, but also withthe administration, because if
anybody took a look at therequest for information that the
Office of Science and Technologypolicy put out about six weeks
(17:50):
ago, it was in asking forproposed reforms to regulation
of artificial intelligence.
This was one of the proposedaction items in the AI action
plan issued by the White Housein July.
The beginning of that RFI,before it gets to the questions
(18:12):
to prompt the public, it laysout various what are
characterizes faulty assumptionsthat there oftentimes is an
inclination to go towardsregulating artificial
intelligence akin to how wewould regulate humans.
And they actually talk abouthuman oversight and human
(18:36):
decision making, and then theygo on and talk about how
healthcare is a sector that isripe for AI.
So I think you will hear atleast some proponents who who
would say, but geez, if you canadequately train in AI, mightn't
it be a more effective tool interms of making both approvals
(18:59):
and denials?
I think we're we're a ways awayfrom a cultural acceptance uh of
that, but I certainly thinkthere is some corner of our
country that is thinking in thatregard, maybe beyond just
corners within payers or vendorsthat serve payers.
SPEAKER_03 (19:24):
But like it or love it, it could solve some of the
concerns that providers haveabout inconsistencies in
decisions and and maybe helpalleviate or bridge some of that
gap.
SPEAKER_01 (19:37):
Yeah, that's a really good point, uh, Rochelle
and Kathy, all good points madeby you as well.
I I think what we're talkingabout here are a couple of
things.
One is the responsible use of AIin this space, um, and that is
to be determined in terms ofwhat the guardrails are going to
be.
Um, as Rochelle said, there weresome really important, I think,
points that would have been inthat regulation that did not
(19:59):
get.
Finalized by CMS.
Hopefully, you know, that will.
And then the other thing is thepoint of adoption and the
literacy of it, as you pointout, Kathy.
I mean, you know, I think it'simportant to meet providers or
payers where they are withregard to that adoption and then
kind of take them along thatjourney in terms in terms of
(20:20):
what is possible in theresponsible use of AI.
And that's something that I dealwith a lot in my practice
because, you know, you both saidit very well.
Not everyone is up to speed onthis, not everyone trusts it.
But there are uses that wouldhelp in many regards, whether
it's consistency or speed,reduction of manual processes
(20:44):
and the like.
But it's just finding wherethose guardrails really should
should exist.
SPEAKER_03 (20:49):
Well, Kathy, you started this discussion with the
definition of priorauthorization.
What's the definition ofartificial intelligence where
you can even begin to regulateor decide how it's going to be
used responsibly in the space ofsomething so important as prior
authorization and access tocare?
SPEAKER_02 (21:08):
That's such a wonderful point about the
definitional inconsistency ofartificial intelligence.
You have some narrow definitionsand broad definitions.
And even when they're close,there's always like a word or
two different between states ordifferent organizations.
(21:31):
And I don't know when we'regoing to get sort of that
driving influence here in theUnited States that kind of has
us heading all towards a singledefinition.
It's kind of like the definitionof specially drug or specially
product in the pharmacy benefitsspace.
(21:53):
But talking about AI makes mewant to ask you both.
Have one of you talk about thewiser model that is set to
launch at the beginning of nextyear?
And that's CAP W, Cap I, Cap S,lowercase E, Cap R model.
(22:14):
It's out of CMMI, that's anacronym.
But what it is, and there's beena lot of talk about it,
certainly at the administrationas well as in Congress.
SPEAKER_01 (22:28):
Yeah, this was uh quite an interesting uh what I
would almost call curveball uhyou know that was that was
thrown.
Um so what it is, uh well justto level set again, prior auth
is a utilization managementtool, and just the concept of
utilization management generallyspeaking is more common in the
managed care context.
(22:49):
Um the Wiser program is set upto pilot uh for original
Medicare, which is more of a feefor service, obviously a fee for
service program.
And so traditionally, prior authwas used in original Medicare in
a very limited set ofsituations.
Examples of which would becertain uh hospital outpatient
(23:09):
department services, some DME,uh, some non-emergency transport
requests, and regardless, thesewere handled by the MACs, the
Medicare Administrativecontractors.
What Wiser is seeking to do iswork with private contractors,
technology contractors, uh thatwould use, they'll use AI tools
(23:30):
and review PAs for serviceswhere it's thought that there's
a high potential for fraud,things such as skin substitutes,
knee arthroscopy for arthritis,osteoarthritis, or those are
good examples.
This causes some concern and hascaused some scrutiny because,
again, now we're talking aboutblurring the lines between a
(23:52):
fee-for-service program and amanaged care program.
We're also talking aboutintroducing more prior auth in
original Medicare, which couldintroduce delays again for
physicians and patients.
And then really, I think thelargest area of scrutiny is the
model itself, whereby thesecontractors would operate on a
(24:14):
recovery basis, meaning thatthey would receive a percentage
of savings.
And that is something that wehaven't seen, or you know, would
certainly frown upon, at leastfrom the managed care
perspective.
Um, and then the last piece isAI again, right?
So we've just talked about howthere's no set definition, we
(24:36):
don't have a mandated frameworkfor oversight, but we have a lot
of information for how CMSwanted Medicare Advantage
organizations to view AI and useit in prior auth.
And one of the couple of thoseconsiderations were you know
such that you would still takeinto account individual facts
and circumstances of the case,not make big sweeping decisions,
(24:58):
and that also there would be nodiscrimination or that bias and
things of that nature that cancreep into these models would be
carefully reviewed and certainlynot take place.
So those are some of the thingsthat that I would point out uh
with regard to Wiser.
SPEAKER_03 (25:18):
Yeah, thank you, Kathy.
I I am not in one of the stateswhere Wiser will be rolled out
initially, but we are watchingcarefully for how that how that
program is impacted.
And Dorothy, you use the wordcurveball, and that was my
reaction when the Wiser modelwas announced because it came on
the heels of proposed rules thatwould really tighten the way AI
(25:41):
is used in prior authorizationfor Medicare Advantaged Plan.
And those those rules or thoseproposals were sort of tabled.
We had a change inadministration while that
proposed rule was was with theagency.
And then this model almostseemed to conflict or just take
a hard right um uh in the sensethat it just hived it from the
(26:06):
approach or the tone of theproposed rule for Medicare
advantage and now whattraditional wood medicare would
be doing.
So a little bit of of kind ofriplash on on the policy
perspective or the approach.
And I think that's the questionpatients and providers want to
see with this wiser model,especially given Dorothy that
your comment that thecontractors have a financial
(26:30):
incentive to deny.
And that's different from theRAC model, where a contingency
fee was was such an uproar adecade and a half ago when that
program began.
But that was payment on the backend where this could be access
on the front end.
And so it really will beinteresting to see how the the
(26:50):
industry and patients respond tothat.
But you also um mentioned,Dorothy, areas where there's a
high likelihood of a fraud oroverpayment or a lot of money at
stake, and you use skinsubstitutes as an example.
And I've been watching thatreally closely because I defend
a lot of providers in mypractice against traditional
(27:11):
Medicare audits and Mac auditsand UPIC audits and rack audits
and skin substitutes are a topicthat's been um highly contested
over the last few years.
And what I like about the wisermodel in that particular area is
it gives me provide growthproviders peace of mind up
front.
(27:31):
Before I purchase this productand spend a lot of money that I
will not get feedback, it's notjust my professional time I
would lose if I have to pay backfor this actual expense.
Having the prior authorizationon the front end, I think in
certain areas could could reallybe beneficial to both providers
and patients.
SPEAKER_01 (27:51):
Yeah, I I think that's a fair, fair point, uh
Rochelle.
And um some of the things here,I mean, with with regard to
utilization management, I mean,I think that's always been the
case that um anything, and I usethe drug example.
I do a lot of work, as saysKathy, in the Part D arena and
(28:11):
um in the drug claim arena.
And you know, whether or not thedrug carries a high risk with it
is always a component of whetheryou're going to apply prior
authorization.
Um, so from that perspective,you know, I definitely
understand where this policy iscoming from, and I understand it
from the perspective of wantingto cut down fraud, waste, and
abuse.
(28:32):
I think again, the componentthat is most concerning or
raises some eyebrows is thatrecovery uh element and doing
that on the front end where youcould really be incentivized to
um you know cut off someone'saccess.
So I think all eyes are going tobe watching how that really
plays out.
SPEAKER_02 (28:53):
It'll be interesting to see what reporting comes out
on this model and at what pace,sort of akin to the transparency
that's being mandated by otherCMS regulated uh plans and
whether Medicare fee for serviceI'll say measures up to that
(29:16):
level of transparency for thisprogram.
SPEAKER_01 (29:20):
Exactly.
And you know, one other thingthat's kind of interesting is
that the uh physician feeschedule final regulation rental
rule came out and it containedsome interesting um uh
arrangements with regard tofinancials around skin
substitutes.
So there again, you you've gotthis weird policy juxtaposition
(29:41):
of coming up with a potentialsolution to reduce those prices
uh that way.
And then my I guess my questionwould be: do you really still
need that prior auth on thefront end?
Uh I guess that all remains tobe seen and we'll have to work
through once these things getimplemented.
SPEAKER_02 (30:00):
Do either of you think the wiser model will have
anything to say about theapplication of AI, harking back
to earlier earlier in ourconversation relative to its
application in MA or in otherlines of business?
(30:20):
Rochelle says she's watching themodel closely.
Should others be watching itclosely as well and with an eye
on what?
SPEAKER_03 (30:30):
Yeah, I I I again I kind of go back to the RAC
program when that was a new andrevolutionary concept and um
hotly debated because of thecontingency fees in that
program.
I think we'll see an evolutioncome out, and that's why it's
being piloted in a few areas,and there will be an evolution
of policy on whether and how andto what extent AI is used in the
(30:53):
guardrails and the protections.
And we will probably seereporting on prior authorization
requests and approvals anddenials.
Uh, and I think that's what weshould be watching to see how
that program may evolve andwhether it's likely to extend to
other geographic areas.
SPEAKER_01 (31:10):
Yeah, another is true, and another interesting
place that we can keep our eyespeeled is in the uh information
that gets released each year forMAOs, Medicare Advantage
organizations to put their uhsubmit their bids for payment.
So theoretically, uh these theseif the Wiser model moves forward
(31:33):
and it does bring down, let'ssay, uh the rising medical cost
trend, which is very significantand a significant issue right
now.
If it does that in the states inwhich it's being implemented, uh
we should see that in the USPCCs, the US per capita costs
that are derived from fee forservice Medicare utilization,
(31:55):
and then that's given to theMedicare Advantage organizations
for them to proxy their bids.
Theoretically, what should startto happen is those costs come
down, and then the plans wouldbe in those states, you know,
have a lower bid target or lowercost target to go against with
regard to their bid.
(32:16):
So we could, I suppose, comparewhether you know it's in place
in those states versus othersand see what plays out in the US
PCCs.
It would be a nice way toanalyze how this is actually
working once we actually startto see results.
SPEAKER_02 (32:34):
So I think it's about time for us to wrap up.
So we've talked about where weare with PA as 2025 comes to a
close.
I would love to hear from eachof you where should folks be
focusing their eyes for PA as2026 launches.
SPEAKER_03 (32:56):
The wiser model is first and foremost what
everybody has their eyes on intraditional Medicare and how
that how that program plays outin the 2026.
We haven't talked a lot aboutstate law policy, and that is
something in our area that weare seeing an increase in state
laws taking initiative toimplement various prior
(33:18):
authorization policies.
Often those are even morestringent than some of the
federal proposed rules, whichcan be great for patient
protections and consumers andconstituents in the state, but
also create complexities forplans that or payers, I should
say, that have plans governed bydifferent bodies of law on how
(33:40):
to effectively administerdifferent rules, as it is
challenging on the provider sideto figure out those processes
and those rules in thispatchwork of state law and
federal law.
And that's just in the priorauthorization space.
We also, as we've kind of beentalking about over the last um
(34:00):
over the last hour here, the thedeveloping framework and
patchwork of AI rules as itapplies in the healthcare space.
Those I think are going to betrends into 2026 to see how
federal policy is developing andevolving, and then how state law
is either following suit ormaybe straying from what federal
(34:21):
policy is doing.
SPEAKER_01 (34:24):
Yeah, I think those are all good things to watch.
I agree, I all eyes on Wiser,and um certainly I think the
Democrats in Congress arealready taking aim at it.
There's certainly a lot ofpushback on it already before it
even starts.
Uh, I agree, you know, the AIframework and whether you know
there's more to come on thatfrom a legislative or even
(34:47):
policy perspective.
Uh, and then um the other thingI would say is just staying
vigilant generally, and thencertainly whether you're a payer
or a provider, it's knowing yourdata, knowing what's happening
to you, and getting control overit, understanding you know what
your denial rates really are andyou know what types of services
(35:08):
and what the rules are so thatyou can start to demystify it a
little bit, regardless of whathappens, you know, on the
legislative or policy landscape.
I think there's still a lot ofjust our operational and data
analysis work there that can bedone.
So it's kind of giving a senseof what you can do while all
this is spinning and changing.
SPEAKER_03 (35:29):
You sparked a good thought there too, Dorothy, um,
that I don't know that we'vetalked about yet, which is kind
of the evolution and rollout ofdifferent gold card, platinum
card type programs that arebecoming more popular and um
whether those are effective tobalance burden and access and
payment as well.
SPEAKER_02 (35:50):
Well, on that note, I'm gonna thank everybody for
tuning in because that gives methe opportunity to say that
Dorothy and Rochelle at least,maybe we'll have another
panelist join them.
We'll be back in early 2026 inwebinar form to talk about
(36:14):
looking ahead in 2026 for priorauthorization.
And I think talking about goldcarding and platinum carding,
given I've heard mixes mixes andfeedback on them, we will have
time to dive into that.
So let me thank everybody forjoining us today.
(36:36):
And thank the Payers Plans andManaged Care Practice Group,
which is bringing you today'spodcast episode.
Bye all.
SPEAKER_00 (36:52):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity, visit American Health
Law.org and stay updated onbreaking healthcare industry
news from the major mediaoutlets with AHLA's Health Law
Daily Podcast, exclusively forAHLA comprehensive members.
(37:15):
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
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