Overview:

The Centers for Medicare & Medicaid Services (CMS) has finalized the landmark Interoperability and Prior Authorization Final Rule, establishing new requirements to streamline prior authorization processes for Medicare Advantage, Medicaid, and other federally qualified health plans. It is imperative for practices to understand and correctly implement these changes to alleviate administrative burdens without compromising patient care or revenue.

Prior authorization remains a leading cause of claim denials, resulting in significant financial losses for providers. In this session, healthcare attorney and compliance expert Osato Chitou, ESQ., MPH, will deliver actionable strategies to navigate this complex landscape. You will learn proven techniques to accelerate approval times, reduce denial rates, and ensure compliance with the new federal mandates.

The Urgent Need for Change:

Recent analyses underscore the critical nature of this issue. A 2021 KFF report found that 99% of Medicare Advantage enrollees are in plans requiring prior authorization for some services. More alarmingly, a U.S. HHS OIG report revealed that 13% of prior authorization denials by Medicare Advantage plans were for services that should have been covered under Medicare rules, often due to the use of proprietary clinical criteria or requests for unnecessary documentation.

Key Regulatory Mandates:

This final rule requires impacted payers to:

• Implement HL7® FHIR® APIs to facilitate electronic data exchange.

• Shorten decision timeframes to 72 hours for urgent requests and 7 calendar days for standard requests.

• Provide a specific reason for all denied prior authorization decisions, effective 2026.

• Add a new measure for MIPS-eligible clinicians to encourage the adoption of electronic prior authorization processes.

Learning Objectives:

Upon completion of this session, attendees will be able to:

• Interpret and apply the updated CMS Prior Authorization guidelines.

• Identify qualifications for faster payments and understand mandated payer response timelines.

• Analyze key reasons for delayed approvals or rejections and implement corrective actions.

• Navigate insurer-specific rules and conduct effective prior-authorization audits.

• Evaluate and select the most efficient prior authorization submission methods.

Areas Covered in the Session:

• In-Depth Rule Analysis: The CMS Interoperability and Prior Authorization Final Rule, including API requirements (Patient, Provider, Payer-to-Payer, Prior Authorization).

• Operational Strategies: Methods to reduce the prior authorization burden, including best practices to mitigate denials and combat improper rejections.

• Process Optimization: A comparative review of submission channels (Standard Electronic Transactions, Payer Portals, Fax, etc.), identifying triggers for prior authorization, and establishing effective follow-up protocols.

Who Should Attend:

This webinar is essential for all stakeholders involved in the revenue cycle and patient care workflow, including:

• Healthcare Executives, Administrators, and Financial Officers

• Compliance Officers, Legal Teams, and Practice Managers

• Physicians, Nurses, and Clinical Staff

• All Revenue Cycle and Front Desk Team Members

• Department Managers and Providers