Photo: Reza Estakhrian/Getty Images
The Workgroup for Electronic Data Interchange (WEDI) has released the results of its most recent survey assessing industry readiness to meet the requirements of the Centers for Medicare and Medicaid Services Interoperability and Prior Authorization Final Rule.
WEDI’s survey looked at compliance for requirements that go into effect on Jan. 1, 2027.
Other requirements start on Jan. 1, 2026.
One of the major requirements that goes into effect in two weeks mandates a new timeline for prior authorization approval: 72 hours for urgent requests and seven days for standard requests.
Payers must provide clear reasons for PA denials. This excludes drugs.
Impacted payers include those who offer Medicare Advantage, Medicaid, CHIP and Affordable Care Act marketplace plans.
On Jan. 1, 2027, payers need to meet application programming interface (API) mandates for patient and provider data access. General API requirements for data exchange begins on Jan. 1, 2027.
WHY THIS MATTERS
With just over a year until the Jan. 1, 2027, compliance deadline, WEDI’s new survey results show that while the industry has made some progress, there is more work remaining in implementing, testing and training to meet the regulatory requirements.
Survey responses from payers show that 43% have not yet started their API requirements work. This is better than the 50% who had not yet started when WEDI released its last survey results in April.
In estimating the current stage of completion with implementing the Patient Access API, 66% of payers estimated they are 25% or less completed, down from 74%. Twelve percent expect to be 75% to 100% completed by the Jan. 1, 2027, deadline.
The majority (42%) of payers estimate a cost of $1 million to $5 million for implementing the API components of the rule.
The top three implementation challenges payers reported are: digitizing prior authorization policies; meeting compliance timelines; and working with third parties that are facing challenges connecting with different systems.
Providers need to implement APIs to enable data exchange. They are also struggling, with less than half, 47%, saying they will somewhat or very likely meet the Jan. 1, 2027, deadline. Forty-seven percent have not yet started implementation and testing.
The majority (55%) of providers remain unsure of the total cost for implementing the requirements and training their employees.
Nineteen percent expect the clinician to directly interact with the API prior authorization process at the point of care with the patient, and 19% expect other clinical staff to use the process.
Providers’ top three implementation challenges are: developing new workflows; having sufficient internal expertise; and coordinating with vendors/health plans on testing.
Sixty-seven percent of vendors said they plan to assist payers and providers in complying with the requirements, down from 84% cited during the April survey.
The survey shows the challenges of moving to new technology, modifying workflows, integrating data streams and digitizing business policies, said Robert Tennant, WEDI executive director.
“With a little more than a year before the (2027) compliance date, it is concerning that 43% of payers and 47% of providers have not begun their implementation process,” Tennant said. “While these numbers are improved from our previous survey in January/February, they signal that significant work remains for the industry.”
THE LARGER TREND
CMS released the rule in January 2024. The final rule seeks to reduce patient, provider and payer burden by streamlining prior authorization processes and moving the industry toward electronic prior authorization.
The April WEDI survey found that more than half of providers and 43% of payers had yet to start work on the API requirements.
Email the writer: SMorse@himss.org