From Promise to Practice: Evaluating the Impact of the Prior Authorization Reform Pledge

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Gordon Jaye: I'm Gordon Jaye. I've been with EnableComp for a few months, but I've spent my entire career in health care.

Over the last couple of decades, I've worked at the intersection of operations policy, patient advocacy, and public and private sectors, including hospitals, complex claims billing, telehealth, and Medicaid outreach, where I've consistently worked to try to improve the patient and provider experience. 

This topic of prior authorization is very timely. This is something that is top of mind for patients. All of us are subject to some prior authorization requirements when we have services rendered.

As a senior executive, I've led national teams across revenue cycle transformation, Medicaid strategy, patient access and experience, and digital innovation. Everybody wants to be able to get their service and their questions answered without having to pick up the phone or interact in person with a provider.

I hold a master's degree in project management and, soon, in public health. That has brought me to a better understanding of the implications of social determinants of health when a delay occurs in the care of a patient due to prior authorization rules.

How do you see the recent prior authorization pledge reshaping operational efficiency and turnaround time benchmarks across workers’ comp and managed Medicaid programs?

Jaye: Managed Medicaid programs and workers' comp are 2 of the most complex claims that are out there in the marketplace.

They would be impacted the same way as any other commercial insurance would be if these rules come to fruition. I'm looking to see how the pledge could reduce prior authorization for services that are routinely ordered by providers—especially those with a strong approval track record and demonstrated medical necessity. These routinely ordered services, which have historically received minimal pushback from payers, are ideal candidates for streamlining. With that in mind, I'm looking forward to seeing how this voluntary pledge takes shape.

One of the things that you hear from providers is that they don't understand all the complex rules that go into getting a prior authorization. When a denial needs to be overturned, the process becomes even more cumbersome. It places a tremendous amount of administrative burden on the practice.

I'm also looking to see how payers roll out their endpoint integration. This can be in the form of robotic process automation (RPA) or even application programming interface (API) technologies that have been on the marketplace for quite some time. However, payer and provider systems, in some cases, are not equipped to integrate them directly.

Most importantly, I'm looking to see how shortened times impact prior authorizations for urgent cases. Obviously, if a case is emergent, it would be in the emergency room where one is not subject to prior authorization. But for urgent situations that require testing or additional testing to confirm a diagnosis, I'm looking to see how that is impacted by these rules and how that timeline is shortened.

Payers have pledged to publish prior authorization metrics and to track accountability through transparency. I'm interested in what type of data they publish, whether semiannually, monthly, or annually, to evaluate how that can be improved upon from the original rollout.

If you think about some of these things individually, I'm looking to see a lot of improvements take place in the prior authorization space. Some of these things go back several years to when they were first proposed under President Trump's first term. The final rule from the Centers for Medicare and Medicaid Services (CMS) was confirmed back in October 2024 during the Biden administration, so it's been a long road. I'm excited and optimistic that some of these changes will improve not only provider relationships with payers, but also patient experiences and the ability to access care without delay when appropriate medical necessity requirements are met.

From your experience, what can commercial and group health payers learn from workers’ comp workflows where prior authorization intersects with clinical review, case management, and legal oversight?

Jaye: When you think about it in that way, because of lack of a national guideline or rule prior to the CMS guideline being published and finalized in 2024, almost every state has its own requirements for prior authorization as it relates to workers' comp. California has a rule for standard submissions requiring that authorizations be approved within 5 working days. Texas allows 3 working days, and Florida has the same. When providers are dealing with patients or payers from out of state, sometimes those rules are not as clear.

How can we first roll out evidence-based rules with digital workflows for routine approval? Do we have to scrutinize every single one of these submissions, or can we have a framework in which some can be very low touch and approved when provider has good history?

When you think about the work queues on the provider side—especially when there are care pods or care teams—these generally include administrative registration, clinical support, and sometimes legal oversight. From that perspective, one would hope that on the payer side, there would be something similar to reduce the turnaround time and obtain all the information they need on the first pass so that a denial is prevented. Working denials can be a nightmare, so making sure to roll out teams that are inclusive of case management, clinical review, and legal oversight is important to cut down on the back-and-forth associated with a claim getting denied or a prior authorization getting denied.

Prior authorization delays remain a top pain point for case managers. Which automation opportunities are realistic today—and where should care teams remain cautious about overreliance on artificial intelligence (AI)?

Jaye: AI has been in the news a lot lately, sometimes for good reasons, sometimes not so much. One has to be cautious in to how they include AI. Some payers have rolled out AI for adjudication of claims, spending mere seconds on making a decision that would take a human minutes, if not hours, to review, including all aspects of clinical necessity for the tests, procedures, and care that may have been rendered.

I would be a little bit cautious about AI. But that does not mean that we shouldn't embed AI as a function or tool within the workflow and have humans make the final decision if a claim is subject to denial due to complexity. I think AI certainly has a role there.

There are technologies, as I mentioned, that have been available in the marketplace to support payer and provider relationships but have been underutilized or not tapped for their full capacity. APIs have been on the marketplace for many years at this point, and can be a good tool to speed up some of the paperwork that needs to be submitted either via fax or manual channels. Even when submissions are made through a portal, it breaks the efficiency with which a prior authorization should be adjudicated.

We can also use natural language processing. Make it simple, don't subject providers or provider staff to jargon that is specific to your payers. Making those types of changes that are market ready today can greatly improve some of administrative burdens that are currently placed on providers.

Interoperability is critical to achieving real-time electronic prior authorization. What data-sharing or standardization gaps are most urgent to close—especially in siloed systems like the US Department of Veterans Affairs (VA), Medicaid, or workers’ comp?

Jaye: As I mentioned, lack of API endpoints is a major gap. It is essential to ensure both the provider and the payer are able to support a real-time or near real-time adjudication of prior authorization submissions. This includes the ability to process nonclinical, automated attachments. Most payers require documentation of clinical or medical necessity, which typically takes the form of an attachment. An attachment then has to be opened, reviewed, and summarized on the receiving end to determine whether it supports the request.

Making sure that we standardize all of these state-by-state rules is also essential. In Medicaid, in particular, there are specific rules from all 50 states. What people often fail to realize is that within those 50 state rules are embedded hundreds of additional payer-specific rules to which one must adhere. I have managed Medicaid outreach and strategy for quite some time, and this was one of the points of frustration for our staff. We had to understand the individual rules for all 50 states. However, there are more than 450 payer profiles across the marketplace within those states. You have to not only be able to understand and adjudicate a request of prior authorization according to those 50 state-specific rules, but you also have to then contend with each of the payers operating within those states.

How do we get to that point of making sure it's a simple process, it's applicable to all states, and that there's a common form or a document that needs to be submitted to make sure that workflows are not misaligned? We want to ensure that when we send a submission through a portal or an API, it goes to all necessary teams before an adjudication is made.

We also want to make sure, if there is a denial, that a clinical provider has looked at it to confirm that is indeed the appropriate outcome based on the documentation submitted.

What key performance indicators or benchmarks should managed care executives prioritize in the next 12 to 18 months to tell if the industry is actually moving toward faster, more patient-centered prior authorization?

Jaye: We all want fast. One of the key components of this voluntary pledge made by more than 50 payers—including UnitedHealthcare, Blue Cross Blue Shield, Humana, and Kaiser Permanente—is the commitment to expedited prior authorization. In total, these payers represent around 75% of consumer coverage. How do we make sure that the turnaround time that has been pledged for near real-time adjudication—targeting 80% of cases—is met?

There is a case study of a Humana trial that they did back in 2023 where they were able to meet those goals. There is some history upon which this can be built, but as an executive, I'm looking to see what the median decision time is going to be. Are they able to adjudicate and provide outcomes or results for prior authorization requests within 1 business day? That's what they have pledged. How do we increase the adjudication rates from what it is now—around 40% or 60% near real-time—to 80% to 90%?

One of the things that one has to be really cautious about is that, yes, if I'm a payer, I can adjudicate all of these submissions within 1 business day—but have I increased approvals, or have I actually increased denial rates? We need to keep an eye on denial rates so that these submissions are carefully studied before a judgment is rendered. On an industry-wide basis, currently, denial rates are estimated at approximately 10% or higher. How do we make sure to bring that number down?

We should also consider patient friction points. How many of these require patient interventions? Generally speaking, prior authorizations are a provider-to-payer relationship. How do we insert the patient into the workflow if there are additional requirements that only the patient can provide?

We also need to make sure that the pledge to reduce the number of codes, procedures, or treatments requiring authorization is significantly fulfilled. We need to see, through the payers and their transparency pledge, the set of codes that will still require authorization and those that have been removed. How do we make sure, annually, that we review this list and provide feedback to the payers to make sure that list continues to shrink?

From a complex claims billing perspective, we are obviously going to be looking to see how quickly a claim is adjudicated as it relates to days to pay. Some of these payers take quite a significant amount of time to adjudicate a claim because there may be denials embedded within it. There may be denials related to prior authorization, so how do we make sure that we are keeping an eye on the days to pay and working to see it reduced?

There are many metrics to examine to determine whether the pledge is actually being adhered to. I love the fact that it is voluntary, because voluntary means that, in all likelihood, payers are not going to challenge it through litigation. If this were a law or a rule issued through CMS, legal challenges would almost certainly be a first step if payers were resistant.

I'm optimistic—not just as a patient advocate, but also as a consumer—to see where this takes us in terms of reduction of prior authorization rules. 

© 2025 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of First Report Managed Care or HMP Global, their employees, and affiliates.