ClearCore Insights recently had the opportunity to join forces with Itiliti Health for a dynamic conversation about one of the most pressing challenges in healthcare today: prior authorization reform. Hosted by Itiliti Health as part of their 2025 Prior Auth Expectations Series, the session brought together our CEO, Karen Norris, and Itiliti Health’s CEO and founder, Michael Lunzer, to explore how payers can approach CMS mandates not just as a compliance burden, but as an opportunity for real transformation.
We’ve rounded up key insights and takeaways to help you understand where the industry is headed and how your organization can get ahead.
The State of Prior Authorization: Why Change Is Inevitable
Michael opened the conversation with a clear message: the time for change is now. Prior authorization remains one of the most antiquated, manual processes in healthcare—often relying on outdated technologies like fax machines. At the same time, payers and providers are under immense pressure to cut costs and reduce the administrative burden. Add in a wave of state-level reforms, CMS interoperability mandates, and growing public scrutiny, and it’s clear that the prior auth status quo is no longer sustainable.
Urgency Is Lacking—But Can’t Be Ignored
Karen shared insights from a series of executive forums hosted by ClearCore Insights throughout 2024, where payer decision-makers openly discussed challenges related to CMS readiness. A recurring theme? A lack of urgency. Many health plans still view the mandate as a “future” problem, rather than one demanding immediate action. Karen noted that stakeholder engagement, accountability, and overreliance on vendors are all major concerns that, if unaddressed, will jeopardize successful implementations.
Prior Auth Reform Is a Business Opportunity—Not Just an IT Task
One of the most eye-opening parts of the discussion was the realization that many payers misunderstand what implementing prior auth APIs actually involves. Karen emphasized that organizations often defer to IT, assuming APIs are purely technical deliverables. But in reality, these APIs are built to support end-to-end business process improvements. If approached correctly, they can create massive efficiencies in operations, improve provider relationships, and drive significant ROI.
As Michael put it, “Do we have to do this? Or do we get to do this?”
Culture Is Everything
The conversation also touched on a critical, and often overlooked, factor: culture. Karen and Michael both agreed that a culture of trust, transparency, and innovation is essential to successful transformation. Organizations that embrace change and empower their teams to think beyond “minimum viable product” are far more likely to see long-term benefits—not just check a box for compliance.
Don’t Wait: Planning Ahead Is Key
So, what’s the timeline? Ideally, health plans should have their solutions implemented by Q1 of 2026. That may sound far off, but given the complexity of testing, vendor coordination, and stakeholder education, the window is closing fast. Especially for smaller regional and Medicare Advantage plans, resource constraints and vendor availability could pose real risks.
What Should You Do Now?
Karen offered a practical path forward: conduct a rapid assessment. Even a 4-week “gap analysis” can help you identify where you stand, where your risks lie, and what actions are needed to move forward. Don’t wait for your software vendor to present the perfect solution—they may not be ready. Instead, take the lead and map out what success looks like for your organization.
Final Thoughts: The Opportunity Ahead
At ClearCore Insights, we believe in helping healthcare organizations move beyond compliance checklists to achieve real, measurable outcomes. As Karen said during the conversation: “I want to see these organizations suffer less.” That’s why we focus on strategic readiness, stakeholder accountability, and cross-functional collaboration.
Thank you again to Itiliti Health for hosting such a valuable conversation. If your organization is still navigating what CMS compliance looks like or how to leverage it for operational transformation—let’s talk.
If you’d like to watch the full webinar replay, you can view it here
