Overview:

The Centers for Medicare & Medicaid Services (CMS) has officially implemented the Interoperability and Prior Authorization Final Rule, establishing new standards to streamline authorization processes and payer requirements. These significant regulatory changes affect Medicare, Medicare Advantage plans, and other federally qualified health plans, making timely implementation essential for healthcare providers. Organizations can now effectively manage prior authorization burdens while maintaining quality patient care and protecting revenue streams.

Prior authorization requirements remain a primary cause of claim denials, resulting in substantial financial losses for providers nationwide. Healthcare attorney and compliance specialist Osato Chitou, ESQ., MPH, will present practical strategies to navigate authorization complexities, sharing proven methods to accelerate approval timelines and optimize reimbursement processes.

Recent analyses reveal critical challenges in current authorization systems, including a 2021 KFF report showing 99% of Medicare Advantage enrollees face prior authorization requirements for some services, with 84% subject to authorization for mental health treatments. An HHS OIG investigation further identified that 13% of Medicare Advantage authorization denials improperly refused coverage for medically necessary services.

The new rule mandates that impacted payers implement HL7 FHIR APIs to enhance health data exchange and streamline authorization procedures. Key requirements include:

• 72-hour decision timeframes for urgent requests

• 7-calendar-day responses for standard requests

• Detailed denial reasoning beginning in 2026

• New MIPS measures encouraging electronic authorization adoption

Why You Should Attend:

Prior authorization complexities continue to challenge healthcare organizations, with improper denials and processing delays affecting both patient care and financial performance. Recent regulatory changes create both obligations and opportunities for providers to transform their authorization workflows. This session provides essential guidance for implementing compliant processes while reducing administrative burdens and denial rates.

Learning Objectives:

• Analyze updated CMS prior authorization requirements and timeframes

• Identify authorization qualifications to accelerate reimbursement

• Understand payer response deadlines and enforcement mechanisms

• Recognize common causes of approval delays and denials

• Navigate insurer-specific rules and documentation requirements

• Implement authorization audits to identify process improvements

Areas Covered in the Session:

• Prior Authorization Regulatory Requirements

• CMS Interoperability and Prior Authorization Final Rule Provisions

• Patient, Provider, and Payer API Implementation

• Authorization Process Metrics and Performance Monitoring

• Burden Reduction Strategies and Implementation Frameworks

• Electronic Submission Methodologies and Best Practices

• Payer-Specific Rules and Documentation Requirements

• Authorization Trigger Identification and Management

• Denial Prevention and Appeal Strategies

Who Should Attend:

• Healthcare Executive Leadership and Administration

• Compliance Officers and Legal Counsel

• Medical Practice Managers and Revenue Cycle Staff

• Physicians, Nurses, and Clinical Providers

• Front Office and Administrative Teams

• Financial Officers and Department Managers

• All personnel involved in authorization processes and revenue cycle management