Healthcare Sector Unites for Standardized Prior Authorization

Prior auth is definitely an administrative burden. Epic looks to help. However, payor accountability is also very much needed and key!

Standardizing what is required across health plans will make it simpler and faster for doctors to get their patients the care they need. We're working with health plans to make payer requirements transparent for clinicians at the point of care and automatically package up the right information to send for authorization. https://lnkd.in/edJWvXG3

The Medicare ACCESS Model is another strong signal that CMS is accelerating the shift toward outcomes-driven, technology-enabled chronic care management. Success in models like ACCESS will come from giving care teams the tools and insights they need to intervene earlier, close care gaps, and improve patient outcomes at scale. The future of Medicare care management is proactive, connected, and outcomes-focused. #ValueBasedCare #CareManagement #PopulationHealth #Medicare #DigitalHealth #HealthTech #ThoroughCare https://lnkd.in/gyiEgiuy

A recent Medicare pilot has transformed the renewal conversation for 2027. The CMS ACCESS model compensates digital vendors based on actual patient health improvements, with the nation's largest commercial payers committing to align with this approach. Chronic care management is evolving from a wellness add-on to a clinically driven infrastructure that focuses on outcomes. Plan sponsors who proactively restructure can capture significant savings, while those who do not will likely face increased costs in their renewals. Check the source. https://lnkd.in/eJnGZmci

I've been talking to healthcare executives about CMS' ACCESS Model. It's interesting to hear why companies are participating, and why they're not. In an interview prior to Hinge Health's Q1 earnings call on Tuesday, CEO Daniel Perez addressed the company's decision not to apply for CMS' ACCESS Model. "We believe the ACCESS program, as currently designed, will not deliver any aspect of the triple aim. Moreover, it's structured in such a way as to necessitate the removal of any clinical oversight, putting one of the most vulnerable patient populations, Medicare patients, at risk," Perez said. Read more here: https://bit.ly/4esNUMO Here's my deep dive on the ACCESS Model: https://bit.ly/4etFYuL

Heather Landi raises a very important question here around CMS’ ACCESS model and the future structure of AI-enabled care management. ACCESS may ultimately be remembered less as a digital health reimbursement experiment, and more as CMS testing a new healthcare operating model in public. The debate is currently being framed around: - reimbursement adequacy - AI safety - digital health economics - clinical oversight Those are all valid concerns. But the more consequential question may be: Who owns longitudinal workflow orchestration once care management becomes AI-augmented and continuously connected? Because ACCESS is implicitly challenging a core assumption embedded in much of healthcare operations today: - that longitudinal chronic care management must remain labor-linear. CMS is effectively betting that: - earlier signal - continuous monitoring - AI-assisted engagement - and outcome-aligned reimbursement... can create a scalable alternative. That creates enormous opportunity. It also creates real risk. Not simply because of AI itself, but because healthcare historically struggles whenever new layers of coordination are introduced outside existing provider workflows. To me, that is the central tension underneath ACCESS: not whether AI participates in care management, but whether the industry can operationalize continuous longitudinal engagement without fragmenting accountability, overwhelming providers, or creating yet another disconnected workflow layer. That is a much larger question than digital health reimbursement. https://lnkd.in/enenXtUA

In less than two months, CMS will launch its new ACCESS model, opening up Medicare Part B to health tech companies willing to help older Americans manage their chronic conditions continuously — not just at their next appointment. Innovation models come and go. But this one is different, because it finally acknowledges something families and clinicians have known for decades: chronic disease doesn't get managed in a doctor's office twice a year. The real work happens between visits, and traditional Medicare has never paid for it. Until now. Will ACCESS work? That's genuinely uncertain. Will it disrupt traditional providers? Very likely. Will it signal where CMS is heading regardless of whether this model succeeds or fails? Absolutely. Every healthcare leader should take a few minutes to understand why. https://lnkd.in/ehPbH2_z  

I have serious reservations about the ACCESS model; it carries real risks for traditional providers, creates new openings for abuse, and raises questions that CMS hasn't fully answered yet. If you click the link below, you’ll see I've written about all of that at length. And yet I know firsthand why a model like this is absolutely necessary. My father managed diabetes, COPD, hypertension, and several other chronic conditions in his later years. He wasn't homebound, so he didn't qualify for home health services. What he needed was someone – or something – helping him stay compliant between appointments. Monitoring his glucose. Tracking his blood pressure. Catching the early signs that something was slipping before it became a crisis. That support didn't exist under traditional Medicare. So instead of paying a modest amount to keep him stable at home, the system waited. It waited until he was out of compliance, until his conditions had escalated, until he needed acute care. By the time Medicare was willing to pay, his hospitalizations had cost upwards of $1 million. That is the absurdity ACCESS is trying to fix. Chronic disease doesn't respect appointment schedules, and the progress – or backsliding – happens between visits, not during them. CMS is finally acknowledging what families like mine have known for years. The model is far from perfect. But let's be clear about what it represents: for all of traditional Medicare's history, continuous in-home support for chronic disease management simply wasn't reimbursable. Outside of risk-bearing ACOs, this is the first time CMS has moved meaningfully in that direction. That’s important not just as a policy milestone, but as a signal of where Medicare is inevitably heading. For the millions of Americans managing multiple chronic conditions without adequate support between appointments, it could be genuinely life changing. https://lnkd.in/eTcjh3sZ

ICYMI: Among a myriad of big announcements from the U.S. Department of Health and Human Services (HHS) earlier this week, the Centers for Medicare & Medicaid Services (CMS) declared that they are adding electronic prior authorization (ePA) under the Health Tech Ecosystem initiative! The initial landmark pledge effort brought the nation’s major health plans to the table. And now, this new initiative claims to be bringing in “everyone else;” - Health systems - hospitals - physician practices - electronic health record (EHR) vendors - and digital health developers According to our friends at CMS, the above organizations are now joining payers as a unified coalition aligned around a single mission: making electronic prior authorization work end-to-end, on time, for every patient. I hope you’re as excited about this news as we are, and to learn more, please check out the blog post below and visit the ePA pledge’s website.

Moving Prior Auth into 21st Century and CMS Health Tech Ecosystem —The initial landmark pledge effort brought the nation’s major health plans to the table. And now, this new initiative claims to be bringing in “everyone else;” - Health systems - hospitals - physician practices - electronic health record (EHR) vendors - and digital health developers