What Healthcare Organizations Need to Know

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By Elizabeth Geigle, MHA, CPHQ, CHC, Health Insurance Regulatory Specialist

On March 31, 2026, the healthcare industry will cross a threshold that fundamentally changes how prior authorization (PA) operates in America. For the first time, Medicare Advantage organizations, Medicaid and CHIP managed care plans, and Qualified Health Plan issuers will be required by the U.S. Centers for Medicare & Medicaid Services (CMS) to publicly post their prior authorization performance metrics. This isn't just another compliance requirement—it's the beginning of a new era of accountability that will reshape competitive dynamics and operational priorities across the healthcare ecosystem.

What's Changing: The New Rules of the Game

Under CMS's Advancing Interoperability and Improving Prior Authorization Processes final rule (CMS-0057-F), health plans must publicly report aggregated prior authorization data that was previously kept internal:

  • Approval and denial rates for prior authorization requests
  • Average response times for both standard and expedited requests
  • Overturn rates on appeal

These performance indicators will be visible to beneficiaries shopping for coverage, providers evaluating which plans to work with, regulators monitoring compliance, and advocacy groups holding the industry accountable. Plans must report their 2025 data by the March 31 deadline, meaning the clock is already ticking.

The rule also establishes specific turnaround requirements: seven-days for standard requests and 72-hours for expedited reviews. These aren't aspirational goals—they're enforceable standards that will be measured and displayed publicly.

While CMS mandates what metrics must be reported, the agency provides flexibility in how organizations present this information on their websites. Health plans have discretion in determining the most effective way to display their data, creating an opportunity to present information in ways that provide meaningful context. CMS has published a Prior Authorization Metrics Reporting Template with recommended formats, including visual presentations such as charts and graphs, but these are guidelines, not requirements. This flexibility is significant because it allows plans to thoughtfully design their public reporting pages to tell their complete story: displaying the required numbers alongside explanatory narratives about clinical criteria, process improvements, and member-focused values. Organizations that use this discretion strategically can differentiate themselves from competitors and build trust with stakeholders through transparent, contextualized communication that goes beyond mere compliance.

Why This Matters: From Private Performance to Public Scrutiny

Prior authorization has long been one of healthcare's most controversial friction points. Providers complain about delays and administrative burden. Patients face uncertainty and access barriers. Yet until now, there's been limited visibility into how well the system actually functions.

That lack of transparency ends this spring. For the first time, consumers will be able to compare plans based on how quickly they respond to authorization requests and how often they approve versus deny care. Plans with higher denial rates and slower turnaround times will be visible alongside competitors with stronger performance metrics. Providers will have data to support their frustrations or validate their partnerships. Regulators will have benchmarks to identify poor performers and target enforcement.

This transparency represents a fundamental shift in market dynamics. Prior authorization performance is about to become a key differentiator in an increasingly competitive healthcare marketplace.

The Ripple Effect: What Organizations Should Expect

The impact won't be limited to health plans. This regulatory shift will create ripple effects throughout the healthcare ecosystem.

For Health Plans: Organizations unprepared for public metrics reporting face reputational risk that could affect membership growth, retention, and regulatory relationships. Plans need to audit their current performance, identify gaps, and implement process improvements before their 2025 data becomes public record.

For Independent Review Organizations (IRO) and External Review Organizations: Since overturn rates on appeal are part of public reporting, the performance of external review partners will directly impact a health plan's public metrics. Expect health plans to scrutinize IRO relationships more carefully, demand faster turnaround times, request detailed performance reporting, and potentially renegotiate contracts to align with these new accountability standards.

For Providers: Transparency creates leverage. Armed with public data showing excessive denial rates or slow response times, provider organizations will have concrete evidence to support network negotiations and regulatory complaints.

For Beneficiaries: Consumers will finally have meaningful data to inform coverage decisions. Plans with strong PA performance can use this as a competitive advantage. Plans with weak performance may lose market share.

Getting Ready: Practical Steps for Healthcare Organizations

The March 31, 2026, deadline is approaching fast. Organizations serious about preparing should consider these immediate actions:

  • Evaluate Your Current Performance: Conduct a thorough audit of your 2025 prior authorization data to understand your approval rates, denial rates, turnaround times, and appeal overturn rates. Identify where you're vulnerable relative to likely industry benchmarks.
  • Assess Your Technology Infrastructure: Meeting seven-day and 72-hour turnaround requirements requires efficient systems and workflows. Many organizations will need to upgrade technology, automate manual processes, or implement real-time tracking capabilities.
  • Review Your External Partnerships: If you work with IROs, utilization management vendors, or other third-party organizations that touch your PA process, now is the time to evaluate their performance and capacity to support your public reporting obligations.
  • Develop Your Narrative: Data without context can be misleading. Organizations should prepare to explain their PA metrics in a way that demonstrates commitment to member access and clinical appropriateness. Transparency doesn't mean perfection, but it does require honest communication.
  • Build Monitoring Capabilities: Public reporting isn't a one-time event. Organizations need ongoing systems to track PA performance, identify emerging issues, and support continuous improvement.

Looking Ahead: Opportunity in Transparency

While the PA transparency era creates immediate compliance pressure, it also presents an opportunity. Organizations that embrace transparency and genuinely improve their prior authorization processes will be rewarded with competitive advantage, stronger provider relationships, and better member experiences.

At ExamWorks UM Strategies, we believe that quality, efficiency, and transparency go hand in hand. The organizations that thrive in this new era won't be those that view transparency as merely a compliance exercise. They'll be the ones that use it as a catalyst for meaningful operational improvement and better service to the members and providers they serve.

The countdown to March 31, 2026, is underway. The question isn't whether PA transparency is coming—it's how prepared your organization will be when it arrives.

Don’t overlook the value of a trusted URAC and NCQA accredited Utilization Management program like ExamWorks UM Strategies to help you navigate these regulatory changes, reduce your operational risk and meet your business objectives.

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