What Happens After Everyone's Compliant? The Prior Auth Question Nobody's Asking

What Happens After Everyone's Compliant? The Prior Auth Question Nobody's Asking

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Everyone in prior authorization is racing right now.

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CMS-0057 has set the pace: 72-hour turnarounds on expedited requests, seven calendar days for standard decisions, public reporting of prior authorization metrics, and a full suite of FHIR API requirements rolling into 2027. The timelines are tight, the stakes are high, and every health plan and PBM in the country is heads-down on compliance work.

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But there's a question that deserves more attention than it's getting: what happens after?

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The Compliance Finish Line Is Actually a Starting Line

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Let's project forward. It's January 2027. Every impacted payer has met their CMS-0057 obligations. APIs are live. Metrics are being reported. Response times are within the mandated windows.

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Now what?

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When every payer meets the same requirements, compliance stops being a competitive advantage. It becomes the baseline — the cost of doing business. The playing field is level again, and the differentiator shifts to something compliance was never designed to address: how well your prior authorization operations actually perform.

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That's where the conversation needs to go.

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And the Regulatory Road Isn't Over — CMS-0062 Is Coming

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Here's something else health plan leaders should have on their radar: CMS-0057 isn't the last word on prior authorization reform. CMS has a proposed rule — CMS-0062, "Interoperability Standards and Prior Authorization for Drugs" — currently under review by the Office of Management and Budget (OMB).

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CMS-0057 deliberately excluded drugs from its Prior Authorization API and process requirements because the standards, processes, and decision timeframes for drug prior authorization differ significantly from those for medical items and services. CMS-0062 is designed to close that gap.

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The proposed rule would introduce new requirements for drug prior authorization across the same set of impacted payers — Medicare Advantage organizations, Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plans on the Federally-Facilitated Exchanges. While the rule hasn't been published yet, OMB review is typically the last step before a proposed rule hits the Federal Register. When it drops, the compliance clock starts again.

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This matters for two reasons. First, the plans that are building their CMS-0057 compliance infrastructure as a one-time project — rather than as the foundation for ongoing operational improvement — will find themselves back at square one when CMS-0062 requirements arrive. Second, plans that invest now in flexible, automated prior authorization platforms that can adapt to new regulatory requirements will be far better positioned to absorb CMS-0062 without another scramble.

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The regulatory trajectory is clear: more automation, more interoperability, more transparency. The question is whether you're building for just the current deadline or for the regulatory direction as a whole.

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Three Questions That Matter More Than "Are We Compliant?"

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Talk to operations leaders at health plans right now, and the compliance work is front and center. But just beneath the surface, there are harder questions that CMS-0057 doesn't answer — and that CMS-0062 won't answer either:

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How quickly can your team make accurate clinical decisions?

The regulation sets maximum response times, but it doesn't tell you how to meet them without burning out your clinical staff. Many payers are still running prior authorization reviews through manual, labor-intensive processes — nurses toggling between systems, cross-referencing clinical criteria in PDFs, chasing documentation from providers. Faster timelines on the same broken process just means more pressure, not better outcomes.

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How much time are clinical staff spending on admin work vs. clinical judgment?

This is one of the most underreported problems in prior authorization. Highly skilled nurses and pharmacists — people you hired for their clinical expertise — are spending a disproportionate amount of their day on administrative tasks. Data entry. Document retrieval. Eligibility verification. Status updates. Every hour spent on admin is an hour not spent on the clinical judgment that actually determines whether a member gets timely access to care.

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How are you handling the appeals and grievances that pile up downstream?

Faster initial decisions are a clear win. But faster decisions don't reduce the volume of appeals — and for many payers, appeals and grievances represent a growing, resource-intensive workload that operates almost entirely separately from the initial PA process. When a case gets appealed, clinical staff often have to rebuild context from scratch because the original decision, documentation, and rationale don't carry forward cleanly. It's redundant work at scale.

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Why Compliance Alone Creates a False Sense of Progress

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Here's the risk: health plans pour significant resources into CMS-0057 implementation, hit the deadlines, and treat it as mission accomplished. Leadership sees the compliance boxes checked and moves on. Meanwhile, the underlying operational problems — the ones that actually drive cost, staff burnout, and delays in member access to care — remain untouched.

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Worse, meeting faster response time requirements with the same inefficient processes can actually increase strain on the operation. You're not doing less work. You're doing the same work under tighter deadlines. Without genuine operational improvement, compliance becomes a pressure multiplier, not a solution.

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And with CMS-0062 on the horizon, the pressure is only going to compound. Plans that treat each regulatory mandate as an isolated compliance project — rather than investing in platforms and workflows that can adapt continuously — will be stuck in a cycle of reactive scrambles every time a new rule arrives.

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This isn't a hypothetical concern. It's the pattern we see playing out across the industry right now. The plans that invest exclusively in meeting the regulatory minimum are setting themselves up for a harder road once the compliance dust settles.

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What the Forward-Thinking Plans Are Doing

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The health plans and PBMs that are positioning themselves for long-term success aren't just building toward a compliance deadline. They're using this regulatory moment as a catalyst to address the operational fundamentals that compliance alone can't fix — and they're building infrastructure that will serve them when CMS-0062 arrives.

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They're automating intake and eligibility verification. Instead of processing incoming requests manually — pulling data from faxes, phone calls, and portal submissions — they're using intelligent automation to create structured cases with eligibility verified before a clinical reviewer ever touches the file. This isn't about replacing human judgment. It's about making sure clinical staff receive clean, complete, ready-to-review cases instead of spending their first 20 minutes on each case just assembling the information.

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They're embedding clinical criteria directly into decision-support workflows. Rather than asking reviewers to manually reference policy documents, formulary guides, and clinical evidence, leading payers are encoding their specific criteria into the workflow itself. Reviewers are guided through consistent, evidence-based evaluations — which improves accuracy, reduces variability between reviewers, and speeds up the process without cutting corners. When new criteria arrive — whether from internal policy updates or new regulatory requirements like CMS-0062 — the system can be updated without rebuilding the workflow from scratch.

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They're connecting initial decisions to downstream appeals and grievances. The best-run operations don't treat appeals as a separate silo. When a decision is appealed, the full context — original documentation, clinical rationale, reviewer notes, member history — carries forward automatically. This eliminates the redundant rebuild that makes appeals so time-consuming, and it gives the appeals team a complete picture from the start.

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They're measuring operational performance, not just regulatory compliance. Beyond the metrics CMS requires, these plans track clinical staff time per case, auto-adjudication rates, first-pass approval accuracy, appeals overturn rates, and time-to-resolution across the full lifecycle. These are the numbers that tell you whether your operation is genuinely improving — not just whether you've met the regulatory floor.

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They're building for regulatory adaptability, not just current requirements. The smartest plans recognize that CMS-0057 is part of a broader regulatory trajectory — one that CMS-0062 confirms. They're investing in platforms that can absorb new requirements without starting from zero each time. Flexible clinical criteria management, configurable workflows, and standards-based integrations aren't just operational advantages today — they're insurance against tomorrow's regulatory mandates.

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The Real Opportunity Is Operational

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CMS-0057 is a meaningful step forward for the industry. It's raising the bar on transparency, pushing payers toward faster response times, and creating accountability through public reporting. CMS-0062, when it arrives, will extend that momentum to drug prior authorization. Both matter — for providers, for members, and for the system as a whole.

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But the plans that treat compliance as the destination — rather than the starting point — are the ones that will struggle once the regulatory dust settles and the focus shifts to performance.

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The real opportunity is to build prior authorization operations that work fundamentally better: faster and more accurate clinical decisions, less administrative burden on the people making those decisions, connected workflows from intake through appeals, and ultimately, faster access to appropriate care for the members who need it.

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That's not a regulatory problem. It's an operational one. And the time to address it is now — while the industry's attention and investment are already focused on prior authorization.

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The question isn't whether you'll be compliant. It's what you'll build beyond compliance that matters.

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How Banjo Health Can Help

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At Banjo Health, we think about this every day. Our platform was built to address the operational challenges that compliance alone can't solve — from automated intake and eligibility, to AI-powered clinical decision support, to end-to-end appeals and grievances management. And because our platform is designed around configurable clinical criteria and adaptable workflows, our customers will be positioned to meet CMS-0062 requirements when they arrive — without another ground-up implementation.

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We work with health plans and PBMs who are thinking beyond the deadline. If you're wrestling with the same questions we've outlined here, we'd love to compare notes.