Healthcare Organizations Struggle with Prior Authorization API Deadline

Survey Reveals Implementation Gaps

Healthcare organizations face mounting challenges in meeting federal interoperability requirements, with 10% of payers and 33% of providers yet to begin work on Prior Authorization Application Program Interface requirements. These findings come from a survey released by the Workgroup for Electronic Data Interchange at the 2026 HIMSS Global Health Conference & Exhibition in Las Vegas.

Implementation of the API requirements becomes mandatory by January 1, 2027, under the Centers for Medicare and Medicaid Services Advancing Interoperability and Improving Prior Authorization Final Rule.

Progress Among Payers Shows Improvement

"We were encouraged to see that the percentage of payers who had not yet begun implementation declined from 43% in October 2025 to just 10% in February 2026," said WEDI Executive Director Robert Tennant.

The rule mandates the use of Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs for data exchange. When implemented, these mandates are expected to deliver streamlined patient data exchange and reduce administrative burden for both payers and providers.

Payer Implementation Status

Survey results show encouraging progress among payers:

• For Prior Authorization API requirements, only 10% have not yet started work, compared with 33% in October 2025 and 42% in January/February 2025
• In estimating completion stages for Patient Access API implementation, 35% estimate they are 25% or less complete, down from 66% in October 2025
• Sixteen percent expect to be 75% to 100% complete by the January 1, 2027 deadline
• The top three implementation challenges include delegated third parties facing connectivity issues with different systems, digitizing prior authorization policies, and securing sufficient funding

Provider Implementation Lags Behind

Providers face more significant challenges in meeting the requirements:

• Thirty-three percent have not started implementation of the Prior Authorization API, with 67% unsure about implementation and testing progress
• No respondents registered any implementation progress in this survey round
• Less than half (47%) expect they will somewhat or very likely meet the January 1, 2027 deadline
• The majority (67%) remain unsure of the total cost for implementing requirements and training employees

Provider Workflow Concerns

The survey revealed uncertainty about how the new systems will integrate into clinical workflows:

• Thirty-three percent expect clinicians to interact directly with the API Prior Authorization process at the point of care
• Another 33% expect interaction with administrative staff
• The remaining 33% were unsure about workflow integration

Provider implementation challenges center on insufficient internal expertise, coordinating with vendors and health plans on testing, and navigating various networks including TEFCA, QHIN, and HIE systems.

Industry Collaboration Essential

The survey questionnaire was developed by WEDI leadership and the WEDI Prior Authorization Subworkgroup. A total of 83 organizations responded to the newest survey, compared with 243 organizations in January/February 2025 and 173 in October 2025.

WEDI was formed in 1991 by then Health and Human Services Secretary Dr. Louis Sullivan to identify opportunities to improve the efficiency of health data exchanges.

"Respondents who completed all three surveys represented a broad cross-section of the industry, including payers, providers, clearinghouses and technology vendors," Tennant said. "WEDI plans to conduct a follow-up survey later in 2026, which will be critical for assessing the progress the industry has made in meeting these complex requirements. Successful implementation will depend heavily on the industry's ability to work collectively and collaboratively."

Looking Ahead

With less than a year remaining before the January 2027 deadline, the healthcare industry faces significant work to achieve full compliance with the new interoperability requirements. The survey results suggest that while payers are making steady progress, providers need additional support and resources to meet the federal mandate successfully.

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Source: Payers, providers face challenges in meeting Interoperability and Prior Authorization Final Rule - HealthcareITNews