This month brought important federal policy updates, payer changes, and early signals of how AI is being embedded into real-world healthcare operations. Below is a concise digest for anyone tracking prior authorization, interoperability, and value-based care.
"AI in healthcare is advancing quickly, but adoption only works when it fits into workflows and meets governance standards. That's where our work at Ethermed is centered — building trust while removing the friction of prior authorization."
— Daniel Friedman, CEO, Ethermed
AI in Practice
Northwell's Agentic AI Pilots
Northwell Health reported reducing the time to generate prior authorization for transfers to skilled nursing facilities from roughly two hours to about six seconds in a pilot, alongside other discharge-planning automation. Details are still high-level but indicate growing willingness among large systems to operationalize administrative AI.
Epic "Healthcare Intelligence" Previews
At Epic UGM 2025, leadership described a push to embed "healthcare intelligence" across the suite, including administrative helpers that can aid documentation and prior-auth-related tasks. Timelines vary; some capabilities target 2026. Buyers should evaluate fit with local workflows and governance.
AMA AI Governance Toolkit
The AMA released a practical toolkit this spring for health systems building AI policies, covering governance roles, vendor evaluation, and compliance. It's a useful reference for committees overseeing clinical and administrative AI adoption.
CIO Sentiment: Embed AI in the EHR
Recent surveys show strong interest in AI for administrative burden reduction, with about half of CIOs rating native EHR embedding as "extremely important." That preference affects whether organizations choose EHR-embedded features or third-party tools.
Payer Policy and Market Moves
UnitedHealthcare: September Policy Updates
UHC published its September 2025 policy and protocol overview, including revisions to medical policies and specialty injectables. Key highlights include updated prior authorization requirements for weight loss and appetite suppression drugs (such as Wegovy and Zepbound), the addition of several injectable therapies to UHC's "Review at Launch" program, and scheduled medical policy and code updates effective October 1. Providers should review plan-specific details and effective dates, especially for state programs and Medicare Advantage.
Payer-Mix Dynamics
Analyses across for-profit systems continue to highlight higher exposure to Medicare and Medicaid, which typically increases scrutiny on utilization management. Expect ongoing tuning of authorization criteria and pre-service requirements as margins tighten.
Federal and Regulatory Shifts
CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)
CMS finalized this rule in January 2024. It requires impacted payers to provide electronic prior authorization APIs, publish metrics, and meet turnaround standards, aiming to reduce manual effort for providers and patients. Many provisions are staged over 2026 and 2027. It remains to be seen how CMS will enforce the rule and how payers may interpret or apply it.
ONC HTI-4 Final Rule (Certified HIT Requirements)
ONC's HTI-4 final rule adds certification criteria that support more efficient management of electronic prior authorization and related workflows, complementing CMS-0057-F by pushing capabilities into certified health IT. Think of HTI-4 as the tech plumbing on the provider side that pairs with CMS-0057-F on the payer side.
AHEAD Model Extended to 2035
CMS extended the Achieving Healthcare Efficiency through Accountable Design model through December 31, 2035, with changes rolling in beginning January 2026. AHEAD brings Medicare, Medicaid, and commercial payers under the same cost-control framework and holds states accountable for keeping healthcare spending within set budgets. In practice, that could mean new requirements for when and how prior authorization is used in participating regions.
NCPDP Retail Pharmacy and Medicaid Subrogation Timelines Revised
HHS set April 14, 2028 as the full compliance date for NCPDP Versions F6 and 15, with an eight-month transition period beginning August 14, 2027. These versions update standards for pharmacy claims, eligibility checks, coordination of benefits, and electronic prior authorization. Covered entities should plan for dual-version support during the transition.
TEFCA Map Tool Goes Live (Beta)
The TEFCA RCE released a searchable map of participants and sub-participants, showing where trusted exchange networks for secure, standardized health data sharing are active across more than 44,000 sites. The tool offers a clearer view of regional interoperability maturity.
Market Signals and Perspectives
ACO and A-APM Participation
MedPAC materials underscore continued growth in accountable care and A-APM participation, with 2024 data used to analyze incentive patterns and EHR and quality benchmarks. The direction of travel supports more data-driven oversight and standardized measures touching authorization.
Debate Over "Prior Auth APIs Solve Everything"
There is ongoing commentary questioning whether standardized APIs alone will resolve delays and burden. Most observers expect a mix of policy, standards maturity, payer policy changes, and workflow-level automation to move the needle.
Policy, payer strategy, and technology adoption are changing fast. Ethermed brings an AI-first perspective on how these changes connect to the day-to-day work of prior authorization, and we'll keep sharing practical guidance as the landscape evolves.
