Winning the Prior Authorization Battle: CMS Rules, Payer Requirements, and Denial Prevention

The CMS Interoperability and Prior Authorization Final Rule continues to reshape how providers, health plans, and healthcare organizations manage prior authorization requirements. As key implementation deadlines approach and payers expand electronic prior authorization capabilities, healthcare providers must understand how these changes affect reimbursement, patient access, compliance obligations, and operational workflows.

Prior authorization remains one of the most significant administrative burdens facing healthcare organizations. Delays, denials, documentation deficiencies, and inconsistent payer requirements continue to impact patient care and create substantial revenue cycle challenges. At the same time, CMS is pushing the industry toward greater transparency, interoperability, and accountability through new electronic prior authorization requirements and reporting standards.

Healthcare attorney and compliance expert Osato Chitou, ESQ., MPH, will provide practical strategies to help providers navigate the evolving prior authorization landscape. Attendees will learn how to reduce avoidable denials, strengthen documentation practices, improve approval rates, and position their organizations for success as new payer requirements and compliance expectations take effect.

Despite ongoing regulatory reforms, prior authorization remains widely used across Medicare Advantage and other health plans. Industry reports continue to show that prior authorization requirements can delay care, increase administrative costs, and create barriers for both providers and patients. Regulatory agencies have also identified instances where prior authorization denials were issued for services that otherwise met Medicare coverage requirements, highlighting the importance of understanding appeal rights, documentation standards, and payer accountability measures.

The CMS Final Rule reinforces the agency’s commitment to improving interoperability and streamlining prior authorization processes. Impacted payers are required to implement and maintain Health Level Seven (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) Application Programming Interfaces (APIs) to support electronic data exchange and improve prior authorization workflows.

Key provisions include:

• Enhanced electronic prior authorization processes through standardized FHIR-based APIs
• Improved data sharing between providers and payers to support more efficient care coordination
• Greater transparency regarding prior authorization decisions and denial rationales
• Continued requirements for expedited and standard prior authorization decision timeframes
• Reporting and accountability measures designed to improve payer performance and responsiveness

Additionally, CMS continues to encourage provider adoption of electronic prior authorization processes through the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category.

Join us for this timely and practical session to learn how the latest CMS requirements, implementation developments, and enforcement expectations may affect your organization—and discover actionable tactics to fight back against unnecessary prior authorization delays and denials while protecting both patient care and reimbursement

• Review updated Prior Authorization guidelines by CMS
• Understand prior authorization qualifications for faster payments
• Know the payor response timelines to speed up approvals
• Understand key reasons for delayed approval or rejection
• Review insurer-specific rules and process
• Identify factors slowing-down the process with actionable prior-authorization audits

• Prior Authorization Requirements
• CMS Interoperability and Prior Authorization Final Rule
  • Patient Access API
  • Provider Access API
  • Payer-to-Payer API
  • Prior Authorization API
• Improving Prior Authorization Processes
  • Prior Authorization Metrics
  • Ways to reduce the prior authorization burden
  • Demonstrating successful implementation of Prior authorization Burden Reductions
• What Prior Authorization Method Should You Choose?
  • Standard Electronic Transactions
  • Payer Portal
  • Multi
  • Payer Portal
  • Fax
  • Telephone
  • Secure Email
• Rules and Requirements by Payer
  • First Order of Business
  • What CPT Codes Do You Use?
  • What About the Drugs?
  • How Will You Send It?
  • How Will You Follow-Up?
• Prior Authorization Triggers
  • Services and Procedures that Often Trigger Prior Authorization
  • Category of medications that Trigger Prior Authorization
• Best Practices to Mitigate Denials
• Combating Denials
• Live Q&A Session

• Healthcare Executives and Administrators
• Compliance Officers & Lawyers
• Medical Practice Managers
• Physicians
• Nurses
• All Revenue Cycle Staff
• Practice Manager
• Compliance Team
• Financial Officers
• Department Managers
• Providers
• Clinical Staff
• Front Desk Team
• Every Member of the Practice/ System

Osato F. Chitou, ESQ., MPH, is the Founder and Principal Consultant of NMOC Healthcare Compliance Consulting, LLC, doing business as Compli by Osato which provides legal and compliance advisory services to Payors and Providers in receipt of Government Healthcare Funds. Ms. Chitou has a deep understanding of Government Healthcare Programs and focuses her services on Medicare and Medicaid Conditions of Participation, Private Equity backed Physician Groups, Payor Contracting, and Effective Compliance Programs.

She is a subject matter expert in Medicare DSNP, CSNP, ISNP, MMP, and PACE regulatory requirements. She presents nationally on issues related to Medicare Advantage risk adjustment, compliance requirements, and best practices related to operationalizing compliance. Ms. Chitou received her BA in Biological Anthropology from Boston University, her MPH from the University of North Carolina – Greensboro and her JD from Rutgers School of Law. Ms. Chitou is admitted to practice Law in New York, New Jersey, and the Supreme Court of the United States.