The Centers for Medicare & Medicaid Services has been working to improve the prior authorization (PA) practices of Medicare Advantage plans in recent years with several successes to report. The agency is now recruiting electronic health record (EHR) vendors and others into the effort with the formation of a health technology initiative that promises to further reduce delays in PA for Medicare beneficiaries.
CMS announced May 5 that it seeks to “bring prior authorization into the 21st Century” by working with EHR vendors to embed electronic PA information flows into EHRs. CMS administrator Mehmet Oz said this initiative will eliminate the use of antiquated technologies, such as fax machines, and relieve health care providers of paperwork that consumes inordinate amounts of clinical time. Oz said existing PA practices can “drag on for days or even weeks,” a process that carries a significant economic cost for physician practices and hospitals.
The Advanced Medical Technology Association (AdvaMed) has expressed concerns about PA practices by Medicare Advantage plans on several occasions. For instance, AdvaMed said in an August 2022 statement that it endorses CMS's efforts to reduce the frequency of inappropriate denials of patient care via PA processes in response to a CMS request for information. AdvaMed said the increasing Medicare beneficiary enrollment in these plans creates a need to ensure these beneficiaries receive the same care as beneficiaries receiving care through Medicare's fee-for-service (FFS) pathway.
In 2025, CMS said a number of major insurance companies had agreed to a “landmark pledge” to streamline their PA processes. That pledge expanded beyond Medicare Advantage plans and included commercial plans for enrollees of all ages. The affected plans cover roughly 80% of Americans according to CMS, which stated that the pledge should speed access to services such as diagnostic imaging and outpatient surgery.
The May 5, 2026, announcement by CMS states that health plans had reported in April that they had eliminated more than 10% of PAs for a variety of medical services. This translates to a decrease of 6.5 million PAs, but one insurer said it would completely eliminate PA for 30% of covered services. CMS stated that nine healthcare systems have agreed to take PA requirements beyond the required minimum by adopting end-to-end workflows across the entire range of PA processes. Seven EHR vendors have also signed on to the effort along with nine payers.
PA practices have received considerable attention from CMS recently, including the Wasteful and Inappropriate Service Reduction (WISeR) program. Announced in June 2025, this pilot program proposes to use artificial intelligence systems, including machine-learning systems, to reduce inappropriate and low-value care for beneficiaries in FFS care.
In April 2026, CMS proposed a set of reforms to PA practices with the objective of improving access to pharmaceutical products. The associated rule, when finalized, would build on the agency's 2024 final rule for interoperability and prior authorization, the scope of which is currently limited to non-pharmaceutical items and services. The April 2026 draft rule for drug PA would also require insurers to publicly report their approval and denial rates for drugs along with metrics for appeals and decision times.