Podcasts about prior authorization

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..

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

In this episode of AUA Inside Tract, Dr. Kevin Koo, endourologist and chair of the AUA Federal Advocacy Committee, is joined by Dr. Grace Hyun, pediatric urologist and AUAPAC board member, to unpack one of the most pressing issues in urologic practice today: prior authorization. Using data from the AUA Census, they explore how increasing administrative burdens are delaying care, adding unnecessary costs and contributing to physician burnout. With over half of urologists reporting that prior authorization significantly affects patient outcomes, this episode highlights the real-world impact of policy on daily practice. Take the AUA Census: auanet.org/TakeCensus Support the AUAPAC: myauapac.org

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

As CMS rolls out the WISeR model, prior authorization is expanding into traditional Medicare for the first time. In this internal Infinx discussion, we explore how providers are beginning to respond, where the opportunities lie, and why proactive preparation is key.

Understanding the New Medicare Preauthorization Pilot: What Agents Need to KnowIf you're an insurance agent, advisor, or just someone who loves to stay on top of Medicare changes, episode 85 of the Insurance Business Babes podcast is a must-listen. Hosts Joanna Wyckoff and Kathe Kline dive deep into Medicare's new pilot program for prior authorizations on certain Part B services—sparking lots of questions (and a bit of anxiety) among agents and clients alike. Here's a summary and further commentary on what you need to know.What's Changing and Where?This new prior authorization program doesn't signal an immediate, nationwide overhaul; for now, it's a six-year pilot launching in 2026, affecting just six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. Importantly, it targets only specific services, not everything under Part B. As Joanna reassured, “It's not a complete change across the board,” so there's no need to panic—yet".Which Services Are Included?There's a preliminary list of 17 service categories that will require prior authorization, including procedures like knee arthroscopy, spinal fusion, epidural steroid injections, implants for sleep apnea, and expensive wound care products. Many of these (like knee scopes and advanced wound care) have been flagged for possible overuse and abuse in the past.Kathe pointed out how this pilot likely aims to rein in unnecessary spending, similar to how the system already handles powered wheelchairs or certain prosthetics nationwide.Impacts for Agents and ClientsJoanna stressed the need for communication: If you have Med Supp clients in the affected states, you should proactively reach out to prepare them—before they hear from a competitor. It's crucial to clarify that Med Supp plans still can't require their own prior authorizations; the requirement comes from Medicare itself.For now, most “normal” Part B services won't require pre-auth, and providers demonstrating “clean requests” may even earn exemptions. AI programs will help process authorizations, but final decisions should still involve a human touch.Looking AheadThough limited for now, both hosts agreed agents should keep a close eye on this pilot. The landscape could shift significantly if results push Medicare to roll out prior authorizations nationwide. Stay informed, keep your clients prepared, and remember—clear, early communication keeps your relationships strong.This episode is sponsored by ⁠CertifiedMedicareAgents.com⁠. Use the coupon code BABES2024 for a free lifetime BRONZE membership.

If your prior auths can't start until someone opens a fax, this episode is for you. Learn how automating document capture is streamlining radiology workflows and speeding up approvals from day one.Brought to you by www.infinx.com

Major U.S. health insurers have pledged to reform prior authorization processes, aiming to reduce delays and administrative burdens. Join us as we explore the details of this announcement, its historical context, and what it means for providers and patients moving forward.Brought to you by www.infinx.com

Welcome to another episode of the Heartland Daily Podcast, where Ann Marie Sheber and healthcare economist Devon Herrick unpack this week's biggest developments in health policy:

Welcome to another episode of the Heartland Daily Podcast, where Ann Marie Sheber and healthcare economist Devon Herrick unpack this week's biggest developments in health policy:

“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.

In the Medicare Advantage Minute we learn how MA plans use prior authorization requirements to help balance the books. This at the expense of patients who are in need of medical treatment for the best opportunity to regain health! Nebraska is taking the lead in the war to make MA plans better for their members. In the Your Medicare Benefits segment we learn how Medicare is likely to cover lymphedema compression treatment items. Do you like to get stabbed? We cover a list of vaccinations recommended for adults. Finally, an advisor known only as "Rusty" takes a question from a couple who are shocked to have been caught by the "Success Penalty" known as IRMAA. IRMAA casts a wide net but there is an appeal process that has shown success in the past. 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" 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.

This week in the Breakroom, Lynn Nonnemaker joins Maddie News to discuss the recent announcement by health insurers to streamline the prior authorization process. Read more in our Regs and Eggs blog post.

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This episode features Laura Dyrda, Vice President and Editor-in-Chief at Becker's Healthcare, and Alan Condon, Editor-in-Chief at Becker's Healthcare. The conversation covers the latest reforms in prior authorization, hospital financial pressures, rural healthcare challenges, and how smart technologies like AI and ambient listening are shaping the future of patient access and operational efficiency.

Genevieve Wood, Senior Advisor at The Heritage Foundation joins to talk about President Trump and Iran

Listen in as Joseph Kim, MD, MPH, MBA; Manish Shah, MD; Martha Grugel, MA, discuss how they manage the prior authorization process for antiobesity agents to improve the quality of their care delivery, including:The information to collect during patient visitsThe available resources to help you submit prior authorizationsThe supporting documents that are often necessary to accompany prior authorizationsHow to address denials and appealsWhen to access manufacturer-based or foundation-based financial assistancePresentersJoseph Kim, MD, MPH, MBAPresidentQ Synthesis, LLCNewtown, PennsylvaniaManish Shah, MDClinical Associate Faculty MS1 PreceptorUniversity of Florida College of MedicineGainesville, FloridaMartha Grugel, MAMedical AssistantWesley Chapel, FloridaLink to full program: https://bit.ly/45P0v8z

The Big Unlock Podcast · Transforming Prior Authorization with AI – Podcast with Siva Namasivayam He shares how AI is being applied to reduce administrative delays, including the use of generative AI to summarize clinical data and intelligent agents to assist with scheduling and information retrieval processes. The conversation also touches on enabling real-time approvals for a majority of cases, designing algorithms informed by physician input, and navigating the shift to remote work. The discussion offers insight into how technology can address systemic inefficiencies while maintaining clinical oversight. Take a listen.

Months into the 2025 state legislative sessions, how are the key issues of prior authorization, scope of practice, and physician wellness playing out? What themes are emerging and how are they different than those of previous years?  Led by AMA President Dr. Bobby Mukkamala, this panel of AMA Advocacy Resource Center attorneys talks about how the AMA is working with national, state and specialty medical societies to address these key legislative priorities.     ⭐⭐⭐⭐⭐

The Medicare Advantage Minute segment once again illustrates the fact that very few appeals were filed by MA victims of prior authorization refusals. However, the majority of those appeals resulted in reversals of the denials! In "Your Medicare Benefits 2025" we learn how Medicare covers insulin, including the newly created $35 monthly out-of-pocket limit! Moments before recording time a plea for assistance arrived from a victim of the barrage of MA plan brutality that happens to everyone who turns age 65. After hearing a radio interview he decided to emerge from hiding and take a chance on Medicare for the Lazy Man. Finally, How can one appeal a Part D lifetime late enrollment penalty? Just listen to find out! 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!" on Amazon.com. Return to leave a short customer review & help future readers. Official website: https://www.MedicareForTheLazyMan.com.

What policies does the American Medical Association support? What does the American Medical Association fight for? What are the biggest struggles doctors face today? American Medical Association CXO Todd Unger hosts.

In this episode of Breaking Health, guest host Payal Agrawal Divakaran, partner at .406 Ventures, speaks with Jeremy Friese, CEO of Humata Health, about prior authorization and how Humata is helping from “both sides of the fax machine.” Friese also discusses his thoughts on the future of AI adoption, how the regulatory landscape looks, and more. He also shares what the transition between physician to entrepreneur was like, what it's like to found and grow companies, and how to select the right VC partners. Links from this episode:  HealthEdge  .406 Ventures Humata Health