Reform of previous authorization: to transform regulatory pressure into a competitive advantage

The reform of the previous authorization (PA) is no longer on the horizon – It’s here.

From the Federal Gold Card Act to a wave of new laws of the States, political decision -makers respond to years of pressure by putting pressure for faster deadlines, less refusal and more transparency.

For payersThese reforms are more than compliance boxes. They are an operational challenge with high issues – and a rare opportunity to modernize the way you manage complaints and use management (UM).

The pressure increases

Recent policy changes oblige payers to rethink complaint operations:

• Gold carding for large -scale approval suppliers – Follow the performance to identify and exempt qualification providers.
• Retroactive denial prohibition – Strengthen the front exam to avoid expensive errors.
• Flexibility of chronic care – Adjust surveillance because certain current treatments no longer require new APs.
• Speciality Low -cost care and sculptures – Recalibrate costs management without these PA control points.
• Faster reversal – Meet urgent deadlines 24 hours a day and standard of 48 hours by automation and staff.
• Transparency rules – Make sure the use of AI in UM is explainable, compliant and true.

For plans that are always based on inherited systems and partitioned processes, these changes could trigger:

Opportunity to modernize

Although these reforms add complexity, they also create a chance to Reinvent operations. By rationalizing the steps of the manual, by integrating workflows and allowing the sharing of data in real time between the teams, the payers can improve precision, accelerate decisions and build members of transparency.

Health plans that modernize complaints can reduce processing deadlines by Up to 30% – In the end, reduce costs, strengthen relations with suppliers and obtain a competitive advantage.

4 steps to act now

1. Evaluate supplier contracts for operational alignment
   Examine the agreements to ensure that they support rationalized processes for gold carding, chronic care adjustments and other exemptions. Alignment of expectations in advance can reduce retouching, improve the satisfaction of providers and save compliance.
2. Evaluate supplier agreements for scalability
   With less steps as a gourmet mechanism, alternative costs for cost transformation such as post-payment journals will have to develop. Make sure that third-party suppliers have the capacity, SLAs and analysis capacities to manage the potential increase in volume without delaying payment cycles.
3. Build internal analysis capacities
   Strengthen internal tools to detect the trends in use, measure supplier performance and anticipate emerging costs. The AI ​​/ ML can be used to return information on the pre-payment processes, helping the plans to remain in conformity and profitable in a post-PA environment.
4. Integrate UM claims and workflows
   The breakdown of silos between UM and complaints services allows coherent rules, shared data and faster resolution – improve compliance and create a more fluid experience for members and suppliers.

From conformity to competitive advantage

End: Payers who treat the AP reform as a compliance exercise will survive. Payers who use it as an opportunity to modernize lead.

Modernization is not only to avoid penalties – it is a question of solving contracts, suppliers, analysis and integration to prosper in a changing market. If you are looking for a way to stay ahead of the competition and the next wave of reforms, it is now time to act.