Podcasts about prior authorization

The ultimate challenge of operating an OBL is staying profitable. In this episode of BackTable, we bring on healthcare administrator Laurie Bouzarelos and interventional radiologist Dr. Mary Costantino to talk through the intricacies of revenue cycle management as an IR managing an OBL. --- SYNPOSIS The conversation covers the full lifecycle of getting paid in an IR practice, from initial patient contact through final claim resolution. Key topics include credentialing, determining medical necessity, coordination of benefits, prior authorizations, and the importance of working with billing and practice management teams experienced in interventional radiology. The episode also examines how EHR and practice management platform selection impacts clinical workflows and reimbursement, and closes with a discussion on payment plans and how emerging technologies, including AI, may shape the future of revenue management in IR-led OBLs. --- TIMESTAMPS 00:00 - Introduction 01:08 - The Importance of Revenue Cycle Management09:29 - The No Surprises Act and Data Transparency12:03 - Professional Societies and Continuing Education17:50 - Credentialing and Taxonomy Codes40:28 - Impact of Insurance Credentialing on Patient Care42:08 - Revenue Cycle Management Walkthrough48:18 - Challenges with Medicare Advantage and Coordination of Benefits54:20 - Covered vs. Non-Covered Services59:03 - Medical Necessity and Insurance Policies01:01:04 - Prior Authorization and Payment Issues01:13:11 - Payment Plans and Compliance01:23:10 - Practice Management Software01:31:10 - AI in Healthcare and Compliance01:38:57 - Final Thoughts --- RESOURCES Medical Group Management Administration (MGMA)https://www.mgma.com/

Prior authorization can cost you more than time. In this episode, we uncover the hidden impact of prior authorization in Medicare Advantage plans, from delayed care and denied treatments to frustrating administrative roadblocks. Learn how these barriers affect your health and peace of mind, and discover why a Medicare Supplement plan may provide the flexibility, access, and control you deserve.

In this episode, Jakob Emerson, Associate News Director, Becker's Healthcare, discusses consolidation across the Blue Cross Blue Shield system, rising friction between payers and providers over coding and denials, and how AI and upcoming CMS prior authorization rules are reshaping the payer landscape.

On Tuesday's show: Beginning in January, a new Medicare program in Texas and five other states will use AI to approve or deny certain services. We learn what that could mean for Houston patients and what it signals about the future of health care.Also this hour: We discuss the city of Houston's current approach to homelessness, and, in particular, giving out tickets to homeless people who can't possibly pay them. We discuss with Kelly Young, president and CEO of the Coalition for the Homeless of Houston/Harris County.Then, we consider how Houstonians can keep the peace at home while navigating holiday traditions that might put an unfair burden on someone in the household. We discuss with Robyn Martin from The Menninger Clinic.And we take you to an immersive multimedia holiday experience at ARTECHOUSE Houston.Watch

Broadcast from KSQD, Santa Cruz on 12-11-2025: Dr. Dawn presents colleague Dr. Paul Godin's essay on why US healthcare fails as a market system . She explains that healthcare violates every assumption of functional markets: patients can't compare options during emergencies, information asymmetry prevents informed decisions, demand is inelastic when one has an urgent medical issue, and trust is essential to medicine and in direct conflict with profit incentives. Since 1988's Knox-Keen Act allowed for-profit healthcare, private equity has acquired and stripped hospitals, while administrative costs consume enormous resources fighting over payments rather than providing care. She contrasts this with European models like Switzerland and Germany where everyone must participate, insurers must accept all patients, and profit on basic coverage is limited. She celebrates a vaccination success story: HPV vaccines have reduced cervical cancer by 50% over 30 years. The American Cancer Society now endorses self-collected vaginal samples for HPV screening, with an FDA-approved at-home kit from Teal Health allowing women to skip speculums and traditional Pap smears. Current guidelines recommend screening starting at age 25, with testing every five years after a negative result. Dr. Dawn issues a health alert about multiple hospitalizations in Santa Cruz County from foraged wild mushrooms identified incorrectly by phone apps. She describes cholinergic toxicity symptoms: sweating, excessive salivation, pinpoint pupils, and abdominal cramping—signs requiring immediate emergency care rather than waiting it out. She offers follow-up vaccine advice: "go in wet, then sweat." Hydrate before vaccination, then take a hot Epsom salt bath until sweat runs off your face. This helps eliminate adjuvants that cause post-vaccine fatigue and aches, which are often misinterpreted as catching illness from the vaccine itself. Dr. Dawn expresses alarm that Kennedy's reconstituted ACIP nearly voted to eliminate hepatitis B vaccination at birth. She notes infants exposed to infected mothers have 99% infection rates, with half becoming chronically infected and half of those developing terminal cirrhosis or cancer. Testing pregnant women misses infections acquired during pregnancy, and 12-16% of delivering women have no test records. Major insurers have committed to covering birth vaccination through 2026 despite the panel's actions. She offers holiday microbiome advice from researcher Karen Corbin: increase fiber intake through steel-cut oats, whole grain breads like Dave's Killer Bread, beans, apples, and alternative pastas made from lentils or garbanzo beans. Cooking potatoes ahead and reheating creates resistant starch that feeds beneficial gut bacteria, reduces inflammation, and even stimulates natural GLP-1 production. Dr. Dawn reviews research proving health insurance saves lives. When the ACA's Medicaid expansion became optional by state, researchers could compare outcomes, finding 8% lower mortality and 19,000 fewer deaths in expansion states over four years. An accidental IRS experiment—sending insurance enrollment letters to only 85% of penalty payers—showed significantly lower mortality among those who subsequently got insured. Studies of gunshot and auto accident victims found uninsured patients died more often despite receiving identical emergency treatment. She concludes with surprising cancer symptoms: chest pain specifically triggered by alcohol consumption may indicate Hodgkin's lymphoma, as vasodilation activates inflammatory chemicals in affected lymph nodes. Fractures from minimal trauma in people without osteoporosis warrant investigation, as 5% of cancers involve bone. Elevated calcium levels double cancer diagnosis risk in the following year and should prompt follow-up testing.

     MEDICARE ADVANTAGE MINUTE:                                                                WHY MA CONTRACT NEGOTIATIONS ARE GETTING HEATED      YOUR MEDICARE BENEFITS 2025:                                                       TRACTION EQUIPMENT Close friend Marlene figured out how to send me a lively online discussion regarding the new Medicare experiment with Prior Authorization. She saw my repeated warnings in some of these online comments. Full disclosure mandated that I read an AI generated list of the exact procedures included within this five year trial program. New client Cal had an unusual introduction to MLM enrollment service. The state of Nebraska, an unfamiliar insurance company and some careless errors conspired to create a less than smooth introduction to my normally stellar client service! Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+)                   Visit us on: BabyBoomer.ORG Inspired by: "MEDICARE FOR THE LAZY MAN 2025; SIMPLEST & EASIEST GUIDE EVER!" "MEDICARE DRUG PLANS: A SIMPLE D-I-Y GUIDE" "MEDICARE FOR THE LAZY MAN: BARE BONES!" For sale on Amazon.com. After enjoying the books, please consider returning to leave a short customer review to  help future readers. Official website: https://www.MedicareForTheLazyMan.com.

A forward-looking exploration of how AI agents, predictive eligibility, and proactive authorization will reshape patient access. This episode closes out the EVB–PA series with a practical look at what's coming next—and how teams can prepare now.

This episode of The Dish on Health IT features Denny Brennan, Executive Director of the Massachusetts Health Data Consortium (MHDC), in conversation with host Tony Schueth, CEO of Point-of-Care Partners (POCP), and co-host Ross Martin, MD, Senior Consultant with POCP. Together, they examine how MHDC is translating national interoperability policy into practical, statewide action, specifically around the CMS-0057 rule.After brief introductions, the conversation quickly turns to MHDC's long history and why it matters. Founded in 1978, before the internet, MHDC guided Massachusetts through nearly every major health IT transition: HIPAA, Meaningful Use, ICD-10, and now interoperability and automation. Denny explains that this continuity has created something rare in healthcare: sustained trust across payers, providers, vendors, regulators, and associations. That trust, he notes, is what allows competitors to work through shared infrastructure problems that no single organization could solve on its own.From there, the discussion turns to why the MHDC community chose to coordinate and support members in their CMS-0057 compliance journey, versus just letting each member organization go it alone. Denny emphasizes that while healthcare is regulated federally, it functions locally. Each state has its own mix of insurers, hospital systems, rules, and market pressures. In Massachusetts, where long-standing relationships already exist, MHDC saw an opportunity to move faster, test real workflows, and generate lessons that could inform efforts far beyond the state.The discussion then moved to how work to improve prior authorization became such a high-priority focus. Denny describes how the process has grown into one of the most disruptive administrative burdens for clinicians. Rules vary by plan, criteria change frequently, and the information providers need is often hard to access in real time. The result is defensive behavior. Offices routinely submit prior authorizations “just in case,” often by fax or phone, simply to avoid denials and treatment delays. That inefficiency, he explains, ripples outward by slowing patient care, driving up providers' overhead, and requiring health plans to spend more time and resources processing and reviewing the required PA alongside the unneeded submissions.The financial impact quickly becomes apparent. Denny points to evidence showing that administrative costs consume a massive share of U.S. healthcare spending, with prior authorization playing a meaningful role. If automation is implemented through a neutral, nonprofit infrastructure, MHDC believes there is a much greater chance that savings will flow back into premiums and public program costs rather than being swallowed by inefficiency.Ross adds an important dose of realism. Prior authorization friction, he notes, is not always accidental. In some cases, operational complexity functions as a utilization control mechanism. That creates a built-in tension between access, cost containment, and patient experience, and helps explain why national reform has moved slowly despite widespread frustration.At that point, the conversation shifts from why this is broken to how MHDC is trying to fix it. Denny walks through MHDC's operating model: convene the full ecosystem early and often. In a recent deep-dive session, roughly 60 representatives from health plans, providers, and the state participated in a working session focused on what an automated prior authorization workflow could realistically look like. MHDC brought a draft framework to the table. The community pressure tested it and surfaced workflow conflicts, operational blind spots, and policy misalignments that no single organization could see on its own.That collaborative process, Denny explains, is the real engine behind adoption. When stakeholders help build the solution themselves, implementation becomes a shared commitment rather than a compliance exercise. It also reduces resistance later because decisions are not delivered top-down. They are constructed collectively.The discussion then turns to FHIR adoption and why, while real, progress has taken time. Denny traces the turning point back to the 21st Century Cures Act, which reframed patient access to health data as a legal right and categorized data blocking as a regulatory violation. That policy shift, combined with the growing maturity of API-based interoperability, created the conditions for real-time data exchange to finally move from theory to practice.Ross provides a historical perspective from the standards side. Earlier generations of health data standards were conceptually elegant but extremely difficult to implement consistently. FHIR changed that equation by aligning healthcare data exchange with the same API-driven architecture that supports the modern web. He points to accelerating real-world adoption, particularly from large EHR platforms, as evidence that FHIR has entered a phase of broad, practical deployment.Although pharmacy prior authorization falls outside the formal scope of CMS 0057, Denny makes clear that MHDC could not ignore it. For many physicians, especially in oncology, dermatology, and primary care, PA for prescriptions is far more frequent and far more disruptive than PAs for medical services. If MHDC solved only one side of the problem, much of the daily burden for clinicians would remain unchanged.Pharmacy prior authorization, however, introduces a new level of complexity. PBMs, pharmacists, prescribing systems, payers, and patients are all involved, often across fragmented workflows. Denny explains that the challenge looks less like a pure technology gap and more like an orchestration problem. It is about getting the right information to the right party at the right moment across multiple handoffs.Ross shares insights from the pharmacy PA research work conducted with MHDC and POCP. One of the most striking findings was the massive year-end renewal surge that hits providers every benefit cycle as authorizations tied to prior coverage suddenly expire. He also reflects on a recent national electronic prior authorization roundtable, where deep stakeholder discussion ultimately led most participants to conclude that today's technology alone still is not sufficient to fully solve pharmacy PA. The tools are improving, but the problem remains deeply multi-layered.As the episode winds down, the tone shifts toward practical calls to action.Denny challenges the industry to separate where competition belongs from where collaboration is essential. Contract negotiations may be adversarial by nature, he notes, but interoperability initiatives cannot succeed under the same mindset. Real progress depends on bringing collaboratively minded people into the room. These are people willing to solve shared infrastructure problems even when their organizations compete elsewhere.Ross builds on that message with a longer-term challenge: sustained participation in standards development. Organizations cannot sit back and hope others shape the future on their behalf. Active involvement in national standards organizations is critical. This is not for immediate quarterly returns, but to influence the systems everyone will be required to use in the years ahead.The episode closes with a clear takeaway. MHDC did not wait for perfect conditions. It moved when the pieces were good enough, tested real workflows with real stakeholders, adjusted in the open, and began sharing lessons nationally. In an industry often slowed by fragmentation and risk aversion, this conversation offers a grounded look at what forward motion actually looks like when collaboration, policy, and technology finally align.You can find this and other episodes of The Dish on Health IT wherever you get your podcasts, including Spotify and Healthcare Now Radio. If you found this conversation valuable, share it with a colleague and be sure to subscribe so you never miss an episode. Have an idea for a topic you would like us to cover in future episodes? Fill out the form and tell us about it. Until next time, Health IT is a dish best served hot. 

In this episode of Healthcare Americana, host Christopher Habig talks with neurosurgeon and healthcare policy leader Dr. Anthony DiGiorgio about the growing crisis around prior authorizations. They discuss how complicated approval processes delay urgent care, burden physicians, and put patients at risk. Dr. DiGiorgio explains why smarter, low-friction models such as gold-carding and stronger subspecialty board oversight could help rebuild trust between physicians and payers. The conversation also covers the 340B drug discount program, which Dr. DiGiorgio has testified about before Congress. He explains how a program originally designed to help low-income patients has become a major revenue source for large hospital systems and often increases costs for Medicaid, Medicare, and private insurance. Together, they offer a clear and accessible look at what is broken in these systems and what meaningful reform could achieve.More on Freedom Healthworks & FreedomDoc HealthSubscribe at https://healthcareamericana.com/More on Dr. Anthony DiGiorgioFollow Healthcare Americana: Instagram & LinkedIN

Changing the Oncology Prior Authorization Story with Exact Sciences This Office Hours will highlight Liz Durkin, Manager of Revenue Cycle as she tells the story of Exact Sciences' journey, from pain points to progress, and provide takeaways for other oncology organizations seeking to change the narrative on prior authorization. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

Kathy Roe, Managing Attorney, Health Law Consultancy, speaks with Dorothy DeAngelis, Senior Managing Director, Ankura Consulting, and Richelle Marting, Attorney, Marting Law, about the latest trends and developments related to prior authorization, from both the payer and provider angles. They discuss what prior authorization is and why it engenders scrutiny, approaches to easing prior authorization's administrative burden, the responsible use of artificial intelligence, the impact of the new WISeR Model, and what to expect in 2026. From AHLA's Payers, Plans, and Managed Care Practice Group.Watch this episode: https://www.youtube.com/watch?v=k2Oi2HnXZOELearn more about AHLA's Payers, Plans, and Managed Care Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/payers-plans-and-managed-care Learn more about AHLA's January 8, 2026 webinar on prior authorization: https://educate.americanhealthlaw.org/local/catalog/view/product.php?productid=1705Essential Legal Updates, Now in Audio AHLA's popular Health Law Daily email newsletter is now a daily podcast, exclusively for AHLA Premium members. Get all your health law news from the major media outlets on this podcast! To subscribe and add this private podcast feed to your podcast app, go to americanhealthlaw.org/dailypodcast. Stay At the Forefront of Health Legal Education Learn more about AHLA and the educational resources available to the health law community at https://www.americanhealthlaw.org/.

This episode announces the launch of CMS's ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) model - a groundbreaking payment innovation that enables technology-enabled care organizations to treat Medicare fee-for-service patients with chronic conditions through outcome-aligned payments rather than traditional fee-for-service. Abe Sutton (Director of CMMI) and Jacob Shiff (Chief AI & Technology Officer at CMMI) explain how the model addresses a fundamental gap in healthcare: while commercial and Medicare Advantage patients have access to digital therapeutics and technology-enabled chronic disease management, original Medicare beneficiaries have been left behind. ACCESS changes this by paying providers monthly fees for managing conditions like diabetes, hypertension, obesity, behavioral health issues, and musculoskeletal pain - but only when patients achieve measurable clinical improvements. The model is designed to be deflationary rather than inflationary, encourages innovation by simplifying go-to-market for digital health startups, integrates with existing risk-bearing models like ACOs, and represents a broader CMMI strategy to shift from activity-based to outcome-based payments while leveraging new AI capabilities to democratize high-quality care. (0:00) Intro(0:57) The ACCESS Model: Advancing Chronic Care(4:35) Outcome-Aligned Payments and Technology(7:40) Encouraging Innovation and Investment(09:23) Practical Implementation and Examples(24:28) Evaluating Success and Future Goals(26:18) Connecting the Dots: Broader CMMI Initiatives(28:40) Generous and Its Impact on Drug Pricing(30:11) Challenges and Benefits of Prior Authorization(35:19) The Role of Technology in Healthcare(37:59) AI and Technology-Enabled Care(40:26) Reflections on Value-Based Care Models(43:51) Encouraging Competition in the Healthcare Market(48:24) Quickfire Out-Of-Pocket: https://www.outofpocket.health/

Every industry has a process that looks small on paper butshapes everything around it. In healthcare, that process is priorauthorization. It is the quiet monster that hides between doctors, payers, and patients, invisible to most until it strikes. When it does, it does not just delay care; it unravels trust, burns out staff, and corrodes the very idea of a coordinated patient journey.

Prior authorization in oncology is notoriously complex, with aggressive payer policies and documentation hurdles that delay care. Join Liz Durkin, Manager of Revenue Cycle from Exact Sciences, as she shares challenges faced before Infinx, improvements since partnering, and how automation and programmatic strategies are reshaping their PA workflows.Brought to you by www.infinx.com

State Laws Banning Prior Authorization For Medications For Opioid Use Disorder Increased Substantially, 2015–23 Health Affairs While medications for opioid use disorder (MOUD) is effective treatment, most patients with OUD don't receive it and prior authorization (PA) has been a barrier to access. Researchers looked at state policies trying to address this barrier, specifically for private health insurance, between 2015 and 2022. Some states adopted “full prohibitions” against PAs while others adopted “partial prohibitions” that allowed PA under some circumstances. Overall, the number of states with at least some prohibition increased from 2 in 2015 to 22 in 2023. In addition, 7 states adopted “full prohibitions” initially, while 15 adopted “partial prohibitions”, with 4 of those 15 transitioning to “full prohibitions” later. Additional research will be needed to assess the impact of these prohibitions, but this study elucidates the current landscape of policy.   Read this issue of the ASAM Weekly Subscribe to the ASAM Weekly Visit ASAM

Reverification Leads to Prior Authorization Automation Live Demo Reverification can uncover coverage changes that require new prior authorizations. In this live demo, we'll show how intelligent automation and AI agents determine when an authorization is needed, initiate it automatically, and keep the process moving without disrupting staff or patient care. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

In this episode of The Dish on Health IT, host Tony Schueth, CEO of Point-of-Care Partners (POCP), is joined by colleagues Brian Dwyer, POCP's Business Strategy Lead, and Seth Joseph, Managing Director at Summit Health Advisors, to unpack their takeaways from the HLTH25 conference in Las Vegas. Together, they reflect on the energy of the event, the conversations shaping the future of health IT, and interviews recorded live from Podcast Row.The trio kicks off by comparing notes on how HLTH has evolved from a flashy innovation show to something more grounded, a space where serious conversations about interoperability, investment, and operational impact are starting to take hold. Seth notes the event's “coming-of-age” moment, where hype gave way to maturity. Brian agrees, adding that the buzz of startups pitching and investors circling was balanced by a sense of realism about implementation and outcomes.AI dominated every conversation, but with a more pragmatic tone than in years past. The hosts discuss how AI is shifting from novelty to necessity, moving from “AI for AI's sake” to purpose-driven use cases. Interview clips from leaders like Taha Kass-Hout with GE Healthcare spotlight “agentic AI,” where autonomous systems could act as trusted colleagues in care delivery, even participating in tumor board decisions to help extend expertise to rural or underserved regions. The group connects this to the ongoing challenge of ensuring data quality and interoperability as the foundation for any AI success story.Laurie McGraw of Transcarent and Kyle Kiser of Arrive Health bring different but complementary perspectives. Laurie underscores AI's potential to bend the cost curve only if applied safely and effectively, while Kyle highlights the growing complexity of affordability and the need for intelligent systems to help patients and providers navigate fragmented benefits and prescription pricing. Seth and Brian note that the shift toward patient empowerment, fueled by AI and transparency, could signal a broader cultural change in healthcare where consumers wield more influence.The discussion expands into value-based care with insights from McKesson's John Beardsley, who questions whether the industry has truly cracked the code after two decades of running at value-based care and interoperability. John also raises an important tension: small innovators are doing exciting things with AI, but scaling those solutions across full workflows remains the real test. The hosts debate whether new payment models, potentially powered by AI-driven insights, could finally make value-based care viable.Policy and regulation also take center stage as Christopher Chen, MD, MBA, Chief Medical Officer at the Washington State Health Care Authority, shares how state and federal efforts are aligning to accelerate interoperability, reduce provider burden, and modernize prior authorization processes under CMS-0057. The hosts reflect on the importance of federal leadership to align incentives across payers, providers, and technology vendors, echoing lessons learned from the early days of ePrescribing.Other memorable interview moments include John Beardsley's commentary on the CMS Interoperability and Patient App Pledges and how better understanding how NCPDP and FHIR standards bridge pharmacy and clinical data silos could help move the needle. Brian and Seth build on that theme, envisioning a future where agentic AI and patient-facing apps work together to drive true engagement and accountability for health outcomes.In the final stretch, the hosts revisit recurring topics such as physician burnout, administrative burden, and structured data chaos, tying them back to the industry's broader need for smarter implementation and aligned incentives. From Christopher Chen's relaying an anecdote about seeing structured data turned into unreadable images that are faxed in to Arrive Health's use of AI to prevent unnecessary transactions, the episode surfaces a consistent theme: technology alone won't fix healthcare, but when paired with aligned incentives, collaboration, and business transformation, it can finally make measurable progress.The episode closes with optimism. Tony, Brian, and Seth agree that while the system is strained, it's also full of momentum, from maturing AI applications to government action and renewed industry alignment. As Tony puts it, “There's a lot to be hopeful about and a lot of work left to do.”Listen to the full episode to hear interviews from the HLTH25 floor, including thought leaders discussing interoperability, agentic AI, and the real-world changes needed to make healthcare innovation stick.Share The Dish on Health IT from Spotify, Apple Podcasts, or Healthcare NOW Radio, Watch extended clips on the POCP YouTube channel

CMS plans to simplify prior authorization for Medicare beneficiaries beginning in 2026. Listen to learn more about changes coming to Medicare Advantage and Original Medicare!   Read the text version  

Getting stuck in the endless loop of prior authorizations? You're not alone! In this session, Dr. Lisa Faast is joined by Aimee Crawley (National Sales Director), Brian Wyer (Director of Sales Support), and Jordan Martin (Senior Manager of Customer Success) from CoverMyMeds to show you how to make the PA process faster, easier, and more profitable for your pharmacy.   **Show Notes:** 1. **Introduction** [0:00] 2. **Myths About Prior Authorizations** [2:20] 3. **Overview of Cover My Meds** [5:25] 4. **Prior Auth Plus Technology* [8:36] 5. **Pharmacy Demo by Jordan Martin** [9:23] 6. **Provider's Perspective and Q&A** [19:47] 7. **Conclusion and Final Remarks** [27:06]     ----- #### **Becoming a Badass Pharmacy Owner Podcast is a Proud to be Apart of the Pharmacy Podcast Network**  

On Episode 88 of Astonishing Healthcare, we're celebrating Women Pharmacist Day (#WPD2025) and sharing stories from four of our amazing team members: Allison Gallant, PharmD (Sr. Strategic Account Executive), Cindy Strassner, RPh (Customer Success Pharmacist), Lorece Shaw, PharmD (Sr. Director of Prior Authorization and Clinical Care), and Hope Nakazato, PharmD (VP of National Business Development). These women aren't just talking about improving healthcare or celebrating one day - they're actively promoting and implementing change, mentoring the next generation of pharmacists, and building systems to improve clinical workflows and member care.Lorece, Allison, Hope, and Cindy highlight their career journeys, insights on leadership, and the importance of mentorship to their personal and professional development throughout the discussion. They offer unfiltered advice on career growth, overcoming obstacles, staying resilient and expressing confidence in yourself, and how to work together to fix what's broken in pharmacy and health benefits. Whether you're interested in "non-traditional" career paths for pharmacists, curious about how pharmacists work in managed care, or just need some motivation to go for the next big opportunity and a reminder that you've got to be prepared and show up with confidence, per Allison and Lorece, respectively, this episode is for you!Related ContentSigns it is time to change your PBM vendor, and how to overcome common hesitations (by Hope Nakazato, PharmD, MBA)AH018 - What's the Right Path? Post-grad Options for PharmacistsPharmacy Benefits 101: Prior AuthorizationsHealth Benefits 101: The Importance of Clinical ProgramsAH040 - Celebrating Women Pharmacist Day 2024For more content and information about this episode, including the show notes and transcript, please visit Judi Health - Insights.

Reverification can uncover coverage changes that require new prior authorizations. In this live demo, we'll show how intelligent automation and AI agents determine when an authorization is needed, initiate it automatically, and keep the process moving without disrupting staff or patient care.Brought to you by www.infinx.com

Michael Liu is a resident physician at Brigham and Women's Hospital. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. M. Liu, K.T. Kadakia, and R.K. Wadhera. Proliferation of Prior Authorization in Traditional Medicare — None the WISeR? N Engl J Med 2025;393:1457-1459.

Confused by Medicare jargon like step therapy or prior authorization? You're not alone. In this episode, we break down exactly what these terms mean, which Medicare plans use them, and practical tips to get the care you need, without the headache. Whether you're new to Medicare or just want to make smarter healthcare decisions, this guide will help you navigate the approval process with confidence.

Ohio is one of six states testing an AI-led prior authorization program for around a dozen medical procedures for patients enrolled in Medicare.

Choosing the right Medicare plan isn't easy. In this episode of The Matt Feret Show, Matt talks with Bob O'Connor, a Medicare veteran who led one of the largest Medicare Advantage markets in the country. They unpack the difference between Medigap vs. Medicare Advantage, how star ratings actually affect benefits, and why prior authorization may soon appear in Original Medicare Part A and Part B.With millions of people facing coverage changes in 2026, this episode helps you avoid common mistakes and make smarter Medicare choices this fall.The Matt Feret Show is Back with Bob O'Connor [2:03]Understanding Medicare Plans – What Consumers Don't See [3:42]Bob O'Connor's Helpful Tips for the Annual Enrollment Period [12:39]Common Mistakes When Choosing Medicare Plans [12:40]Bob O'Connor's Best Advice for Choosing a Medicare Plan [1:03:56]Connect with me via the podcast website, LinkedIn, Facebook, and Instagram.Check out Bob O'Connor LinkedInThe Matt Feret Show is about thriving in midlife, retirement, and beyond. Each week, Matt shares smart conversations on Medicare, Social Security, retirement planning, health, wealth, wellness, caregiving, and life after 50.Explore more episodes and sign up for The Matt Feret Newsletter: TheMattFeretShow.comNeed Medicare help? Book a no-obligation consultation: BrickhouseAgency.comWatch full episodes on YouTube: The Matt Feret ShowSubscribe on Apple, Spotify, or YouTube for more insights on wealth, wisdom, and wellness in retirement. Hosted on Acast. See acast.com/privacy for more information.

In this episode, Terry breaks down the upcoming Prior Authorization pilot programs launching for Medicare Part B Professional Services on January 1, 2026, and for Ambulatory Surgical Centers starting December 15, 2025. She outlines which medical services will be impacted and what providers need to know as these changes roll out. Terry also shares the […] The post Medicare's Prior Auth Pilot: What It Means for You appeared first on Terry Fletcher Consulting, Inc..

In this episode, Terry breaks down the upcoming Prior Authorization pilot programs launching for Medicare Part B Professional Services on January 1, 2026, and for Ambulatory Surgical Centers starting December 15, 2025. She outlines which medical services will be impacted and what providers need to know as these changes roll out. Terry also shares the […] The post Medicare's Prior Auth Pilot: What It Means for You appeared first on Terry Fletcher Consulting, Inc..

Still waiting for that MRI test to get approved? Physicians are just as frustrated as patients with the prior authorization process, and too often, they take the blame for delays caused by a system they don't control. Tune in as Dr. Daniel Davis, Shoulder & Elbow Surgeon at Rothman Orthopaedics, explains what a prior authorization is, why it was created, who's reviewing your requests, and what physicians can do to reduce denials. To learn more about Rothman Orthopaedics, or to schedule an appointment with Dr. Davis, visit RothmanOrtho.com today!

Attorneys Jon Jablon and Nick Bonds break down some of the issues around administering prior authorization requirements, including their use as a cost-containment tool, the procedural aspects, perceptions, and the impact that can have on plan participants. They also discuss some of the regulatory guardrails being put around prior authorizations at the state and federal levels, and some of the key questions for plan sponsors to consider when designing and implementing prior authorization requirements.

Send us a textHave you ever had your health plan deny a treatment that your doctor says you need? Well, you're not alone. But there's good news: People who appeal insurance denials often win. In this episode of CareTalk Podcast: Healthcare. Unfiltered., hosts John Driscoll and David E. Williams dig into the history of prior authorization, why denials are so common, and what patients can do to fight back.

We go inside Northwestern Medicine's Innovation Engine to see how they are solving healthcare's biggest challenges with Kali Arduini Ihde, Director of Ventures and Innovation at Northwestern Medicine. Kali is at the forefront of bringing emerging technologies into one of the country's top academic health systems to help shape the future of patient care through innovation. She leads the Northwestern Medicine Healthcare Accelerator, which partners with AI and digital health startups to solve real, high-impact challenges in healthcare. We discuss the value of creating organized programmatic innovation to solve important problems (prior authorization, physician burden, supply chain) in a safe space that allows for co-creation to accelerate scale.

In this episode of The Dish on Health IT, POCP CEO and host Tony Schueth sat down with Dr. Julia Skapik (SVP & CMO at PurpleLab, practicing physician, member of the HL7 Da Vinci Clinical Advisory Council, and outgoing HL7 International board chair) and Dr. Steven Waldron (Chief Medical Informatics Officer at the American Academy of Family Physicians and Co-Chair of the Da Vinci Clinical Advisory Council). Together, they explored how clinicians are shaping interoperability and standards development through the HL7 Da Vinci Project's Clinical Advisory Council (CAC).Tony opened by framing the discussion: interoperability looks different at the point of care, and the provider voice is critical in making standards practical. Julia and Steve introduced themselves by highlighting both their clinical work and their roles within Da Vinci. Julia described her experience with clinical data exchange and Data Exchange for Quality Measures (DEQM) work, and Steve explained how his decades in clinical informatics led him to co-chair the CAC.Why HL7 Da Vinci Project ExistsSteve provided a primer on HL7 and the role of implementation guides in constraining optionality, so standards work in the real world. He emphasized Da Vinci's collaborative model—bringing payers, providers, and vendors together. Julia added that Da Vinci's strength lies in defining practical, feasible solutions the government can later adopt into regulation. She noted this industry-led, government-leveraged approach is why Da Vinci solutions have gained traction.The Da Vinci Project CAC's RoleJulia explained the CAC gives clinicians a venue to contribute without the unrealistic expectation of weekly hours of standards work. The council distills provider feedback and ensures workflows make sense in practice. Steve underscored its strategic role: CAC members participate in Da Vinci's steering committee (though without voting power) and help produce content that reflects clinician priorities.Clinical Challenges and OpportunitiesWhen asked about top challenges, Steve focused on accelerating adoption. Clinicians are tired of multiple payer portals; they need solutions that simplify, not add layers. He noted Da Vinci studies early adopters to identify what's working and how to spread best practices. Julia brought in her day-to-day frustration: being blindsided when payers second-guess treatment plans after the fact. For her, seamless data flow at the point of care would let providers close loops quickly and reduce burden.Progress to DateJulia highlighted how Da Vinci has reduced tensions between payers and providers by creating space for collaborative problem-solving. She pointed to patient access and real-time eligibility/coverage checks as areas where providers feel real relief. Steve added that having clinicians consistently “at the table”—via CAC, open invitations, and health system involvement—is a big step forward, even if imperfect.Workflow Alignment and UsabilityThe conversation then turned to the CAC's recent report on usability and workflow. Julia stressed that standards must fit into diverse care settings. Training, audit data, and clarity about why data matters are crucial—otherwise, boxes won't get clicked, and data quality suffers. She provided examples, such as prior authorization questions, that should be resolved automatically to avoid burdening providers. Steve expanded on the strategic approach: learning from innovators, cataloging obstacles (like ROI calculation), and identifying opportunities (education, ROI tools, developer engagement). He illustrated how real-time prior auth workflows must account for triaging between clinicians and back-office staff, not just “dump” everything on providers.Prior Authorization Pain PointsBoth guests dug deep into prior authorization. Julia cited a successful MultiCare Regents pilot and her own frustrations with stuck ePA requests and payer variability. She described patients enduring multiple unnecessary visits due to PA roadblocks. Steve echoed this, recalling clinicians' frustration with nonsensical requirements (e.g., annual PA for diabetes test strips). He argued that half-measures—like real-time denials without alternatives—aren't enough; systems need to provide actionable options to avoid delays in care.Policy and RegulationThe panel then addressed broader policy topics. On CMS's recent digital ecosystem pledge, Steve was skeptical: pledges are good, but clinicians want action and alignment across TEFCA, QHINs, and standards. Julia compared pledges to past attestations—checking boxes without measuring outcomes. Both agreed that alignment of business cases with regulatory requirements (as in CMS-0057) is key to sustainable progress.When asked about price transparency and quality measures, Julia shared insights from her PurpleLab work on claims analytics, arguing that integrated data can drive smarter decisions for providers, payers, and patients. Steve stressed the importance of transparency to spur competition among clinicians and the promise of moving beyond claims data toward richer clinical data exchange via Da Vinci's CDex and PDex work. Julia added a practical note: today, provider office care coordinators and payer care coordinators rarely communicate. Standards that connect those two sides could be transformative.Final ThoughtsSteve's call to action: clinicians should engage where they can—whether by advocating within their organizations or learning through Da Vinci's education tracks. Julia encouraged listeners to press their vendors and payers: “What are you doing with Da Vinci? Will you support these solutions on my behalf?” She emphasized that early involvement is both strategic and practical as regulations like CMS-0057 loom.Tony closed by thanking Julia and Steve for bringing the clinical voice to life and reminded listeners that interoperability is a dish best served hot.Related MaterialsHL7 Da Vinci Confluence PageAccelerating DV Adoption by Providers – CAC Insights ReportCAC Statement on Prior Authorization Burden Reduction BallotHL7 Da Vinci LinkedIn PageHL7 Da Vinci Project: MultiCare & Regence Case Study on Early Implementation & Real-World ROICatching FHIR: Lessons Learned from Achieving the First Prior Authorization Automation via HL7® FHIR®

In this episode, Steven Berkow, Senior Advisor for Value-based Care at InterSystems, and Robert Tennant, Executive Director of the Workgroup for Electronic Data Interchange, discuss the evolving landscape of ePrior authorization. They share insights on regulatory changes, industry collaboration, and what healthcare leaders should know as the 2027 compliance date approaches.This episode is sponsored by InterSystems.

In this episode of the American Shoulder and Elbow Surgeons Podcast, hosts Dr. Brian Waterman and Dr. Peter Chalmers interview Drs. Adam Bruggeman and Dr. Brad Bushnell about their advocacy efforts surrounding insurance prior authorization. 

This episode highlights a client conversation on how intelligent automation and AI agents streamline eligibility verification and prior authorization for PT/OT practices, while human specialists manage exceptions for a complete, tech-enabled solution. Listeners will also hear how seasonal re-verification surges are handled with flexible workflows that reduce denials and improve turnaround times.

In this episode of Disruption/Interruption, host KJ interviews Dr. Paola Ballester, CEO and Co-founder of EasyPA, about the broken state of prior authorizations in healthcare. Dr. Ballester shares her journey from pediatrician to tech founder, the real-world impact of administrative burdens on patients and clinicians, and how her AI-driven platform is streamlining processes to put patient care back at the center. Key Takeaways: The Real Cost of Prior Authorizations [2:05] – Administrative hurdles in healthcare lead to denied claims, lost revenue, and wasted time, forcing clinicians to choose between paperwork and patient care. Empathy Drives Disruption [4:35] – Dr. Ballester’s deep empathy for patients and providers inspired her to create a solution that addresses the root frustrations in the system. AI as a Force for Good [27:05] – EasyPA’s AI platform modernizes prior authorizations, making them 10x faster and giving clinicians more time with patients, not paperwork. Systemic Change is Possible [36:45] – With new technology, regulatory mandates, and a focus on patient-centered care, the healthcare system can move beyond outdated, inefficient processes. Quote of the Show [19:40]:"The assumption that physicians need to prove on a per case basis that their intent is anything other than to provide direct patient care based on evidence-based standards is wild." - Paola Ballester Join our Anti-PR newsletter where we’re keeping a watchful and clever eye on PR trends, PR fails, and interesting news in tech so you don't have to. You're welcome. Want PR that actually matters? Get 30 minutes of expert advice in a fast-paced, zero-nonsense session from Karla Jo Helms, a veteran Crisis PR and Anti-PR Strategist who knows how to tell your story in the best possible light and get the exposure you need to disrupt your industry. Click here to book your call: https://info.jotopr.com/free-anti-pr-eval Ways to connect with Dr. Paola Ballester: LinkedIn: https://www.linkedin.com/in/paola-ballester-md-7738a9a8/ Company websites: easypa.ai How to get more Disruption/Interruption: Amazon Music - https://music.amazon.com/podcasts/eccda84d-4d5b-4c52-ba54-7fd8af3cbe87/disruption-interruption Apple Podcast - https://podcasts.apple.com/us/podcast/disruption-interruption/id1581985755 Spotify - https://open.spotify.com/show/6yGSwcSp8J354awJkCmJlDSee omnystudio.com/listener for privacy information.

Dr. Donna Milavetz, chief medical officer for Regence, talks about how prior authorization helps make health care safer, more effective and more affordable, and the pain points that the industry is committed to improving.

In this episode, Molly Gamble sits down with Dr. Shiv Rao, Founder and CEO of Abridge, to discuss the company's newest breakthrough: a real-time prior authorization solution launched with Highmark and Allegheny Health Network. Dr. Rao shares why this milestone marks a shift from passive to active AI support, how Abridge is reducing clerical burden for clinicians, and what it means for patients, payers, and providers navigating prior authorization challenges.

This episode features David Byrd, Senior Vice President at Infinx, as he walks through a proven four-step prior authorization process that helps reduce denials, accelerate turnaround times, and improve patient access. Listeners will hear how technology and human expertise combine to deliver scalable results across specialties while supporting better patient and staff experiences.

Dr. Jeremy Friese knows medicine from both sides. A practicing radiologist and technology executive, he's seen firsthand how administrative burden undermines care. In this episode of NEJM AI Grand Rounds, he walks through the origins of prior authorization, explains why he believes artificial intelligence can close the gap between patients and payers, and argues that real reform means showing your work—just like in math class. At Humata, he's combining human oversight, LLMs, and interoperability to try to fix a broken system. For clinicians overwhelmed by back-office complexity, this conversation offers both urgency and optimism. Transcript.

From Prior Authorization Chaos to Clear AI Orchestration Prior authorization isn't just broken — it's unsynchronized. On this episode, Evan Martin, VP of Revenue Cycle Management at ZoomCare Inc as well as Host and Producer of The Wilshire's IT RevCast, shares what happens when real-time care delivery meets a fragmented, rule-heavy prior auth system that can't keep up. With just one authorization specialist covering 50 clinics, Evan paints a clear picture: today's healthcare moves fast, but prior auth is still stumbling through a maze of plan-specific rules, outdated workflows, and underperforming automation tools. We explore how even routine imaging, meds, and mental health services become tangled in conflicting payer policies and benefit silos. Evan breaks down the bottlenecks, the firefighting, and the policy blind spots — plus why simply layering automation on top won't fix it. The real opportunity? An orchestrated model powered by agentic AI triages, retrieves, and routes the right information to the right place — so human teams can actually focus on patient care. This isn't theory. It's the lived complexity of treating patients while waiting for permission — and what the future could look like if we finally got the process in tune. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

Navaneeth Nair, Chief Product Officer, and Jonathan Aguiar, Senior Solutions Engineer, share how embedding AI driven prior authorization directly into the EHR keeps providers in their familiar workflow while giving supervisors and leadership complete operational visibility. Discover how digital and human agents work together behind the scenes to accelerate approvals, prevent denials, and adapt to changing payer requirements.

CMS is rolling out prior authorization for traditional Medicare. This Office Hours panel breaks down what the WISeR model means for providers, how AI is involved, and what steps to take now—whether you're in a test state or watching for what's next. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

Evan Martin joins us to break down the daily chaos of managing prior authorizations in a real-time care model. From retro auths to plan-specific rules and underwhelming automation, Evan reveals why today's processes are out of sync — and what an agentic AI solution could look like to finally orchestrate it all.Brought to you by www.infinx.com

What happens when managed care surges in IVF, reimbursements drop, and physicians are expected to do more work for less?Dr. Ravi Gada and Manish Chhadua are back on the show, and they don't hold back. Dr. Gada is a partner at one of the largest independently owned practices in the United States and he and Manish co-own and operate a firm called CloudRx, In this episode, they dig into:What 70 fertility centers are doing to slash administrative costs from prior authorization chaos How medication side savings are shifting into the medical services side (and what that means for practices)Changes in the payer market and insurer preferences you need to know aboutWhy Organon and Follistim have gained so much market share in the past 5–7 yearsWhy academic fertility center ratings are shockingly low (and what private practices can learn from that)

Faxed orders, scanned attachments, and inbox folders shouldn't be the reason prior authorizations are delayed. Yet for many radiology groups, that's still the case. Manual document capture creates friction at the front of the process—forcing staff to rename, sort, and route incoming faxes before a prior auth can even begin. In this episode, we explore how automating document capture accelerates the entire prior authorization workflow. From identifying STAT orders to extracting key order details and triggering auth submissions, we'll walk through how imaging centers are using AI-driven tools to minimize lag, reduce errors, and scale operations without burning out staff. Joining us is Charulata Nevatia, a healthcare product leader with deep experience in workflow automation. She'll share what high-performing radiology groups are doing differently and what steps you can take to modernize intake and boost auth readiness. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

CMS is rolling out prior authorization for traditional Medicare. This Revenue Cycle Optimized panel breaks down what the WISeR model means for providers, how AI is involved, and what steps to take now—whether you're in a test state or watching for what's next.Brought to you by www.infinx.com

“Delay, Deny . . .”— Feds take aim at prior authorizations that block patients' access to care, surgeries, drugs they need; Electrodiagnostic testing with computers—does it add up for diagnosis? Are there non-surgical options for goiters? Chili peppers confer heart, cancer, longevity benefits; Will stem cells deliver a cure for insulin-dependent diabetics? Vitamin C reprograms skin cells to reverse age-related thinning.

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