Passport to Access

I think about access the way I think about travel. Before you cross any new border, you need to understand the terrain, what's changing, what's stable, and where the checkpoints actually are. Right now, the terrain around prior authorization and payer coverage is shifting quickly, and here's what my team and I are watching, because the headlines about this shift are only telling half the story.

The Terrain Looks Like It's Opening Up...

Over the past several months, national payers have made real, measurable progress on prior authorization reform. UnitedHealthcare, Aetna, Cigna, Humana, Elevance Health, and the Blue Cross Blue Shield companies collectively eliminated 11% of prior authorizations across a range of services this year, representing 6.5 million fewer prior authorization requirements for patients (Fierce Healthcare, April 27, 2026). Cigna cut its own prior authorization volume by roughly 15%, and Aetna reports standardizing 88% of its volume, with more than 95% of eligible requests approved within 24 hours (Fierce Healthcare, April 27, 2026). Humana is rolling out a national gold card program in 2026 that waives prior authorization for providers with a proven record of appropriate requests (Humana, policy.humana.com).

If you read only the press releases, it sounds like every border checkpoint just got faster. For established care, that's genuinely true.

...But a New Technology Doesn't Travel on the Same Passport

Here's the piece my team understands all too well: none of these programs were built with a brand-new technology in mind. Every one of these programs runs on the same fuel, a history of claims data that proves a service is low-risk and rarely requested inappropriately. A technology that launched 18 months ago hasn't built that history yet. It's traveling without the stamps that get well-established technologies waved through. When there's no option for a pre-service review, the physician is left at a crossroads: move forward with the procedure knowing the claim will likely be denied, or choose a different course of treatment for the patient, one that may mean a more invasive procedure and a longer recovery.

I've watched this play out directly in CMS's WISeR Model, which launched January 1, 2026, and uses AI alongside clinical review to evaluate medical necessity for select Medicare services in six pilot states. One of WISeR's flagship-targeted categories, skin substitutes, was included specifically because Medicare Part B spending on that category exceeded $10 billion in 2024, following a period of rapid utilization growth (Ensemble Health Partners, February 20, 2026, citing a September 2025 HHS OIG report). That detail matters operationally: rapid, appropriate adoption of a new technology can produce a spending curve that looks, statistically, almost identical to overuse. The system doesn't automatically know the difference. The company on the other end of that review has to show it.

Layered on top of this, several payers are also standardizing which criteria set they use for medical necessity decisions. Priority Health moves to 2026 InterQual criteria on July 13, 2026, and Medical Mutual transitioned from MCG to InterQual criteria in April 2026. Operationally, this is genuinely good news once we're inside that framework, since a technology mapped cleanly to InterQual criteria travels across payers far more smoothly than one requiring a custom argument every time. But getting mapped into that framework in the first place takes deliberate, early groundwork; it doesn't happen automatically just because the framework exists.

Even the Best Guide Can't Issue You a Passport

This is the conversation we have with clients long before launch of a new Patient Access Program: my team can read the terrain, build the argument, and find every open door at the border. What we can't do is manufacture the years of claims history, the published clinical evidence, the coding plan, or the documentation habits a company didn't build ahead of time. That work has to happen on the manufacturer's side, and it has to start early. Here's what needs to already be true before we ever submit a case:

●     Build your evidence package around the payer's actual question, not just the regulatory one. Clinical superiority

and medical necessity are different arguments, and I've watched strong products stall because a company only had

the paperwork for one of them.

●     Get your coding and coverage plan in place before launch, not after volume starts climbing. I've watched companies

try to retrofit this once utilization had already taken off, and it's a much harder trip to make than starting early.

●     Map early to the criteria frameworks payers are actually converging on, so the evidence work travels across payers

instead of needing to be rebuilt at every border.

●     Build clean, consistent documentation habits with your providers from day one. Gold carding and similar programs

reward a track record, and the earlier that record starts accumulating, the sooner your technology stops being the

traveler stopped at every checkpoint.

Manufacturers don't have to build this alone. PRIA's services start well before patient access ever touches a case, and we work alongside our clients from the earliest stages to develop these strategies for success.

Any Legitimate Stamp Gets the Passport Through

This is the part of the job I care most about leading well: when the first door is closed, my team doesn't stop, we look for the next legitimate one. If prior authorization isn't offered for a given service, we check whether a predetermination or pre-service review is available instead. If that path is closed too, we look at whether a formal patient complaint or grievance is the mechanism that forces a first look at the case. None of these are workarounds. They're payer-defined pathways that exist for exactly this situation. We don't always find one that opens, but my rule for the team is simple: we don't stop until we've exhausted every legitimate avenue, and we don't settle for the first door being closed as the end of the story. The patient doesn't care which door we tried. They care that we didn't stop looking.

Where This Series Goes From Here

I don't think the story here is that prior authorization reform is bad news, it's real progress for care that's already established. But I want this series to be the map for the part of the journey that doesn't show up in the press releases: the specific route my team has to take, stamp by stamp, to get a genuinely new technology, and the patient waiting on it, the same fair review that established care already gets. That's the terrain my team works in every day, and it's the terrain I want to walk through with you, one stop at a time.

Sources: Fierce Healthcare (April 27, 2026); Humana (policy.humana.com); CMS WISeR Model (cms.gov); Ensemble Health Partners (February 20, 2026), citing HHS OIG (September 2025); Priority Health provider bulletin (May 11, 2026); Medical Mutual provider notice (April 13, 2026).

Please contact the PRIA team to talk about getting the first stamp on your innovation's passport.