From partial fixes to full transformation: Why payers must act on ePA now

Prior authorization (PA) has long been one of healthcare’s most frustrating processes. For providers, it means endless faxes, phone calls, and staff hours spent chasing approvals. For patients, it means delays in treatment and even abandoned therapies. And for payers, it means wasted administrative spend, strained provider relationships, and reputational risk.

Electronic prior authorization (ePA) was meant to fix this. By moving requests and decisions into digital workflows, it promised faster approvals, less paperwork, and greater transparency. But despite years of effort—via SCRIPT transactions for pharmacy benefits and proprietary portals for medical benefits—adoption has been limited. Workflows remain fragmented, inconsistent, and rarely integrated into provider systems.

That’s why CMS-0057-F is such a turning point. Finalized in 2024, the rule requires impacted payers to implement FHIR-enabled APIs for prior authorization, with compliance deadlines beginning in 2026. CMS-0057-F shifts ePA from optional to required and sets expectations that will likely extend beyond federally regulated markets.

This blog explores what ePA is, 5 reasons payers should accelerate adoption now, and practical tips for getting started.

What is electronic prior authorization?

Electronic prior authorization is the automated, standards-based exchange of PA requests and decisions between providers and payers.

Instead of phone calls or faxes, FHIR APIs handle the full lifecycle:

• Coverage requirements discovery (CRD): Provides a standardized way for healthcare providers to check if prior authorization is needed for a service or item, along with the coverage rules that apply.
• Documentation templates & rules (DTR): Provide structured templates that clearly outline the documentation needed for a request, helping cut down on rework and delays.
• Prior authorization support (PAS): Enables electronic submission of requests and ensures providers can track request status in real time.

Together, these create a real-time loop that makes PA faster, more transparent, and easier to integrate into provider workflows.

Why now?

The urgency is clear. Under CMS-0057-F, impacted payers must:

• By January 1, 2026: Enforce new decision timeframes (72 hours for expedited requests, 7 days for standard) and provide specific denial reasons.
• By March 31, 2026: Publicly report 2025 PA metrics and submit them to CMS.
• By January 1, 2027: Have a fully operational Prior Authorization API live in production.

Missing these deadlines risks CMS scrutiny, corrective action, financial penalties, and reputational damage. Beyond compliance, waiting means holding on to high costs, weaker provider networks, and member dissatisfaction—while competitors move ahead.

Yet adoption is still limited. According to CAQH’s 2024 Index Report, only about 35% of prior authorizations are processed fully electronically, with many payers and providers still using paper, fax, and phone as part of the process.

5 reasons to act now (beyond compliance)

1. Reduce costs

Manual prior authorization isn’t just slow—it’s costly. According to the 2024 CAQH Index, payers spend about $3.41 per manual PA transaction compared to just $0.05 per fully electronic PA. That’s a savings of more than 98% per request. Multiply that across thousands of transactions, and the opportunity to cut costs while freeing up resources is massive.

2. Boost HEDIS and STAR ratings

Delays in care directly impact member satisfaction and quality measures. Faster approvals through ePA can improve HEDIS and STAR performance, leading to stronger CMS ratings, reimbursement benefits, and better retention.

3. Cut delays

Today, patients often wait weeks for PA decisions. With ePA, providers can submit requests in minutes and get responses in hours or days. The AMA reports that 93% of physicians say PA causes care delays, and nearly 40% of patients abandon therapy altogether. Streamlined approvals mean faster starts, fewer drop-offs, and healthier members—reducing complaints and costly churn for payers.

4. Strengthen provider satisfaction and reduce burnout

Provider frustration with PA is one of the biggest sources of dissatisfaction with payers. Manual processes mean endless calls, faxes, and portal logins, leaving staff burned out. According to a 2024 AMA survey, 89% of physicians say PA contributes to burnout, with an average of 13 hours a week spent completing PAs.

Payers feel the strain too: significant internal staffing is devoted to PA, often requiring multiple team members per request plus heavy manual follow-up. ePA eases that burden on both sides, creating a faster process that strengthens payer–provider relationships and supports better network performance.

5. Future-proof and scale

Healthcare is moving rapidly toward API-based interoperability. Implementing ePA now positions payers not only to meet CMS-0057-F requirements but also to scale for digital quality measures, value-based care, and real-time analytics.

Practical tips for getting started

Launching ePA doesn’t mean tearing everything apart. The key is moving smart and fast. Here are some key shifts to make early:

1. Start with a phased approach: Roll out functionality incrementally to meet CMS deadlines while spreading costs and minimizing disruption. Use early phases to pilot with select providers and refine workflows.
2. Lay the technical foundation: Add a modular FHIR API layer to your existing systems. This gives you flexibility to meet CMS deadlines without a full system overhaul.
3. Prioritize reporting now: Start capturing metrics on electronic PA volume, decision times, and denial reasons. You’ll need it for the March 2026 reporting requirement, and gaps are costly to fix later.
4. Design for providers first: Make the process intuitive with clear documentation templates and workflows that fit into provider EHRs. Adoption depends on ease of use.
5. Align internally: Get leadership support, assign ownership for ePA rollout, and ensure compliance, operations, and provider engagement teams are all aligned.
6. Engage providers as partners: Pilot early, get their feedback, and provide training to make the transition smooth. Provider buy-in is critical for success.
7. Measure ROI across three dimensions: Track the impact on staffing (how many resources PA consumes), workflow efficiency (how quickly requests are completed), and accuracy (fewer errors or pended requests). These metrics prove value beyond compliance.

The bottom line

Electronic prior authorization isn’t just about checking a CMS compliance box. It’s about fixing one of healthcare’s biggest pain points. Payers who act now can cut costs, improve provider relationships, boost quality scores, and deliver faster care for their members.

But the opportunity goes further. By building an API-first, FHIR-native foundation, payers not only meet CMS-0057-F deadlines but also create a scalable platform for digital quality measures, value-based care, and analytics. Those who delay risk scrambling to catch up, while early movers gain a lasting competitive edge.

That’s where Firely comes in. We combine deep FHIR expertise with enterprise-grade tools to help payers accelerate compliance and unlock lasting value. With our support, you don’t just meet deadlines, you build a future-ready platform that turns regulation into opportunity.

Ready to get started? Get in touch today to book a strategy session or demo with our CMS interoperability experts.