Jessica Forgette-Gedeon, give us your thoughts on this topic.
Jessica Forgette-Gedeon, director of operations, APS Medical Billing: While gold-carding could reduce the administrative burden of prior authorizations and improve access to important tests like molecular diagnostics and biomarker testing, it may still take time before it is widely implemented. Insurance carriers continue to change their prior authorization requirements and are becoming more creative in their policies and requirements. It is important to track denial trends and identify which carriers are responsible. At the same time, collecting data that demonstrate appropriate use of these tests could help support gold-carding efforts. Collaboration among laboratories, billing organizations, and payers, along with the use of AI tools to monitor authorizations and flag issues early, may help move the industry closer to achieving that goal.
Marc Kellner, what is your experience with streamlining prior authorizations?
Marc Kellner, MBA, VP of product management, Quadax: Authorization has to be done as upstream as possible to avoid a retro-authorization situation. We approach the prior authorization problem in three facets: ensuring we have a strong assessment strategy that facilitates an upstream authorization, inserting automation so we can unburden staff and automate the submission workflow where possible, and facilitating the response when clinical intervention is required to get the authorization. This answer applies to patient access, authorization, eligibility, claims, and denials.
Andi Brooks, can you comment on prior authorizations?
Andi Brooks, VP of client services and practice management, APS Medical Billing: Prior authorizations are a significant administrative burden on providers and can cause delays in care. In August 2025, CMS was able to work with Medicare Advantage carriers to improve their prior authorization processes to reduce administrative burdens and improve carrier turnaround times. The current administration is only offering Medicare Advantage carriers a 0.9 percent increase in CMS funding for their Medicare Advantage patients. This lower-than-expected increase threatens to negatively impact any gains achieved in the prior authorization process, as carriers will now be looking for ways to keep money in their pockets. We may see prior authorization processes go backward now, with these gains possibly reversing through increased documentation requirements or more stringent clinical guidelines and policies. I am concerned we will see additional impacts on the back end with more denials and denial automation, large volume requests for supporting documentation and medical records to show why service was performed, post-payment audits, et cetera. Payers will find ways to claw back revenue every way they can to make up for the 0.9 percent increase. To add to this, the value-based billing cost was $76 billion more than Medicare would pay under fee-for-service, so carriers need more ways to reduce payments and new ways to claw money back
Dr. Tuthill, as I think about Henry Ford and its expansion, does consolidation and sheer size help in your efforts to bill and collect?
Dr. Tuthill (Henry Ford): I don’t think so. It just increases the error queue. It becomes more complex when you have more performing laboratories. If you have three or four different performing laboratories, you may have to leverage different billing providers or services. We’re now using three to five billing services for professional and outreach billing. The complexity of the ordering and testing also becomes at odds with one another. The test menus themselves become topsy-turvy. You find out people are still doing CK-MB for myocardial infarction, and those get denied—“Why aren’t you using troponin?”
I have not found there to be an economy of scale. There may be an economy of scale partnering with vendor services that could help us do the job better. We are still trapped inside Epic. One might suggest that pathology and lab medicine would be better served by a third-party billing service that could help adjudicate these problems and take better care of our patients’ pocketbooks and what shows up in their mailboxes. It might help labs justify using outside billing because they can improve performance in terms of denials as well as prior authorization efficiencies.
The bigger you get, the more complex it is, the more problems you have. We have a dedicated revenue team embedded in pathology informatics now. It is another strategy that is helpful for people if they’re trying to adjudicate it, because it’s the lab system sending to the billing system of whatever service you’re using, whether Epic or a third party.