NatRevMD

#195 The GLP-1 Bridge Just Broke Your Prior Auth Workflow

• NatRevMD • Episode 195

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WE ARE RE-AIRING THIS EPISODE BECAUSE IT MATTERS RIGHT NOW. 

On July 1, 2026, the Medicare GLP-1 Bridge went live. Every independent practice with Medicare patients on Wegovy, Zepbound KwikPen, or Foundayo for weight management is now facing retrospective prior authorizations routed through a central processor most billing teams have never worked with. 

The AMA released physician guidance on June 26. The workflow is new. The documentation burden is heavier than most practices have modeled. And prior auth was already the fastest-growing revenue threat independent practices face. 


In this episode Dr. Heather walks through: 

WHAT WE COVER 

  • Why prior auth denials are silently eating clinical time and revenue 
  • The dollar amount your practice is losing every month (and how to calculate it) 
  • The 5-step workflow to manage prior auth without drowning your team What every practice needs to change this week 

"Prior auth has a dollar amount attached to it. Most practices never calculate it." 

THREE ACTIONS THIS WEEK 

1. Calculate what prior auth is costing your practice in staff hours, denied claims, and clinical time 

2. Set up a central prior auth tracker (do not run this out of email threads) 

3. Train the team on the Medicare GLP-1 Bridge central processor workflow before the backlog compounds

SPEAKER_00

I want you to think about last week. How many hours did your staff spend on the phone, navigating phone trees, sending faxes back and forth with insurance companies just to get a prior off for a patient done? Alright, so it does feel like things are getting worse. You're not imagining. A recent survey from AMA basically found that 90% or almost 90% of physicians report that prior off delays are interfering with patient care. And it is definitely one of the biggest admin burdens in healthcare. So today we're going to be talking about updates with prior off. We're going to be talking about some tools that some of our practices are starting to use. So the entire system is getting an overhaul. It is necessary. And as of January of this year, the old way of doing things is on its way out, right? On its way out, being the keywords there. So the rules have changed, and we just want to make sure that you guys are aware of things that are going on so that you do see denial spikes and cash flow changes that you know what is going on. So we all know prior authors pain. One of the biggest frustrations with Medicare bandage plans has been this waiting game of trying to get prior authors approved. So you submit a request and you wait, sometimes 10, 14 days for decision. So good news is that the new CMS role forces those Medicare bandage plans to make a faster decision. So that's seven calendar days for standard requests and just 72 hours for urgent requests. Obviously, sounds like good news, but the problem is that we're starting to see that pairs are going to be much stricter with this, right? So they may deny requests instantly if they're missing a single piece of required clinical documentation. So it decreases this back and forth so that they can meet that metric. So you do have to be more careful that the submission has to be perfect when you are trying to get it approved. So obviously, you know, things like advanced imaging or complex procedures, you just really want to make sure that incomplete submissions is limited because it could be an automatic denial that then you have to go and deal with and could potentially lengthen that process. But again, they've made a decision, so it meets the metric, but at the same time, they're going to become more strict. So the other thing that's changing is, you know, one of the benefits of traditional Medicare was again that lack of need for prior auth requirements. And that is changing. CMS has launched basically this new pilot program called WISER, W-I-S-E-R model, which stands for wasteful and inappropriate service reduction. And as of January, this program now requires prior auth for 17 specific outpatient services for traditional Medicare. So this pilot is actually running in six states. So it's Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. If you operate in one of these states, you now have to get pre-approval for these services. So there is a list of these procedures that is necessary. We will get the link and put it in the show notes. So fundamental shift basically in how you manage those traditional Medicare patients, and obviously is going to require making sure that your team knows when to get those and to set up a workflow for those Medicare patients. Just a quick reminder: as you guys know, we have a couple tools for you guys and we are building more as we speak. We have right now a tool to help with patient AR called the margin playbook and then eligibility training, which is a detail playbook for you to put into place in your practice. Again, both of those show notes are in the link. All right. And so the last change, right? The third change that we're going to talk about today is about fax machines. So the new CMS rule mandates that by 2027, so we got some time, payers must provide a fully electronic prior auth process, ideally through an API. So this is gonna mean that it's going to require even those small payers. I mean, the big payers, I think, have already done this. It's really the small payers. No more phone calls, no more faxing, clinical notes. It will be a direct digital connection that they're now requiring. So obviously huge opportunity to reduce errors, but only if your practice technology is going to be ready. So you do want to make sure that your practice management software is going to be one of those that is going to be connected with the payers so that you can take advantage of that. All right. So to recap, so new seven-day, 72-hour decision for those Medicare Advantage prior authors, that wiser pilot to be aware of if you're in one of those six states for traditional Medicare of again, those 17 services, and then that shift to electronic prior auth processes again for those payers that don't already have that today. So as you guys know, for many of our practices, they're the ones who are doing eligibility and prior auth. And so these are really important things for you to recognize and know so that you can be prepared. So now what can you do with this information? So here are a few action steps you can take now knowing this information. So the first thing is do you have a list of your procedures and payers that require prior auth? Just you could just start with again those top five procedures that your practice performs that typically require prior auth. Who then is requiring that prior off? And so maybe just something to do a gut check on if you're seeing that their decisions are happening faster. Okay, great. But was it automatically denied? And if it was denied, why was it denied? So that you can evaluate your process for prior authors and update that the following month to make sure that there are no clerical errors, everything's getting submitted correctly the first time. Again, you should be getting decisions faster, but those decisions may be denials if those are not done correctly. Obviously, really great if you do have a prior auth checklist based on your audit, you know, what is that checklist your staff can follow so that they know how to submit those and make sure that those denials are avoided as much as possible. And so that checklist can be handed to your front desk staff or whoever is managing this process. I'm a big believer of actually recording these, these, the steps. So actually screen share and go through the steps. That way you have a bank of recordings that a new staff member can look and review. Or if you've got somebody who's out and somebody who doesn't do this all the time, they can review the videos and then be able to jump in and help. And then last, I do think looking at your EHR, your PM software, and then just understanding what options are you going to have in 2027 in order to do that connection with the payers for prior authors so that you can benefit from that electronic process. So just a few quick tips and hopefully this helps. And the last thing I'll add is we've had, we actually have an amazing urgent care that we work with. They're a larger practice out in California. And they actually, they're the most innovative group I think we've worked with in regards to evaluating technologies for automation. I think AI and automation, that's always the buzzwords that we're hearing. And it's on one hand, it's nerve-wracking, right? Because you don't even know which vendor to pick. You don't know which thing to automate first. Even on our side, from an RCM perspective, we're having those same conversations internally of how do we work smarter, not harder, but also not get lost in trying all this innovation that, you know, slows the team down. So they are evaluating some vendors out there for eligibility and prior auth to try and automate this. And I've got some vendors out there that, you know, we've met with. I think I don't have an answer of who's the best or who you who you should go and check out. What I'm asking is if this is a big part of your practice, if you have a ton of eligibility denials, if you have a ton of prior authors and it's requiring a large workforce, then I think it's time to start evaluating vendors. Some of that is, I think, is going to come along with the EMR and the PM software vendors who are trying to get into the AI automation space. Some of it's going to be third-party vendors that probably are bought up by the PM softwares over time. Either way, I think you need to identify something because I think the way the future's going, and again, this is just my opinion. So just take it for what it is. I think it's going to be necessary that we get creative. So highly recommend searching some vendors that are out there. As always, I'm keeping a close eye on the vendors that our clients are using. And if there's a slam dunk, I will be happy to share it. So hopefully this helps you guys just get the updated information about what's going on with prior authors and use that information to help improve your team. All right. And as always, please share this with a friend. Leave us a review on wherever you're listening to this podcast and subscribe as it helps us grow an audience. So thanks much, and we'll talk to you soon.