Transforming prior authorization: What benefits professionals need to know for 2025

Published:

December 12, 2024

For benefits professionals, compliance is more than an obligation—it’s an opportunity to streamline care access, reduce frustrations, and enhance the overall employee benefits experience.

Prior authorization has long been a contentious process in health care. Providers often see it as a barrier to patient care, while health plans recognize the process as essential for cost control and care quality. As we head into 2025, however, regulatory shifts and technological advancements are transforming prior authorization into a tool that benefits professionals can leverage to improve employee health outcomes and satisfaction.

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)–of which some provisions are set to take effect by 2026–mandates faster decision-making, improved transparency, and better data sharing throughout the prior authorization process. Combined with state-level reforms, these changes will require both health plans and benefits administrators to innovate. For benefits professionals, compliance is more than an obligation—it’s an opportunity to streamline care access, reduce frustrations, and enhance the overall employee benefits experience.

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Written by

Brian

Covino, M.D., FAAOS

Dr. Brian Covino is Chief Medical Officer at Cohere Health, bringing over 25 years of experience as a practicing orthopaedic surgeon, serving as a partner at Knoxville Orthopaedic Clinic, and directing the value-based care program at OrthoTennessee. He holds a bachelor’s degree from Harvard University and an M.D./M.S. from Georgetown University School of Medicine. Dr. Covino completed his surgical training at the University of Virginia and a fellowship at The Cleveland Clinic Foundation. He served as Co-Director of Parkwest Medical Center’s Joint Replacement Center and was among the "Best Doctors in America" for 20+ consecutive years.

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