Insurers struggle with Medicare electronic prior authorization shift

The Medical Group Management Association (MGMA) reports that insurers face significant hurdles in meeting the January 1, 2027 deadline for electronic prior authorization in Medicare Advantage and Medicaid programs. This transition to digital submissions stems from a Centers for Medicare & Medicaid Services (CMS) mandate, which has exposed gaps in three critical areas: identifying which services require approval, creating electronic documentation templates, and submitting requests electronically.

Madison Hynes, MGMA’s associate director of government affairs, addressed these challenges at the MGMA Annual Conference 2026 in San Antonio. Several insurers have privately indicated they may fail to complete all three steps by the deadline, though MGMA strongly opposes any extension. Instead, the association argues that providers need improved access to electronic tools integrated through their electronic health record (EHR) systems to comply with the rule.

The CMS regulation, identified as CMS-0057, already sets strict processing timelines: standard prior authorization requests must be handled within seven days, while expedited requests require a 72-hour turnaround. Denials must include clear justification. However, MGMA questions whether these timelines are being uniformly enforced. Some insurers publish prior authorization data—such as denial rates—as CSV files buried in difficult-to-handle websites, forcing providers to search across multiple payer platforms for essential information.

MGMA has called on CMS to consolidate this data into a single, accessible portal, which would simplify contract evaluations for providers.

MGMA’s 2026 regulatory burden report reveals that 90% of medical practices experienced an increase in prior authorization demands over the past 12 months.

Beyond Medicare Advantage, MGMA warns against expanding prior authorization requirements in traditional Medicare. Since January, CMS’s WISeR model has deployed artificial intelligence tools to evaluate requests for specific services in six states, Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Attendees at the MGMA conference confirmed encounters with these automated reviews, raising concerns that cost-saving algorithms could lead to unjustified denials.

MGMA also opposes mandatory electronic prior authorization under the Merit-based Incentive Payment System (MIPS), though the proposed 2027 physician fee schedule would initially make compliance optional. The association is advocating for legislative solutions, including the Improving Seniors’ Timely Access to Care Act, which already has 290 House cosponsors, nearly a supermajority. This bill would formalize key Medicare Advantage prior authorization rules at minimal cost and has gained significant traction. MGMA also supports the Reducing Medically Unnecessary Delays in Care Act and continues to monitor electronic prior authorization policies for prescription drugs.

The bill’s legislative window is tight: federal funding for related programs expires on December 11, and MGMA views it as a strong candidate for inclusion in year-end spending legislation. While broader dissatisfaction with prior authorization delays persists, the January 1, 2027 deadline remains the immediate priority. Compliance with this rule could fundamentally alter how insurers and healthcare providers coordinate, unless proactive measures are taken.