NCQA Says Payer PA Pact is a 'Promising Step'

While revenue cycle executives are skeptical of the voluntary pact between payers to reform prior authorization, the NCQA’s VP of federal affairs sees it as a significant step forward.

While revenue cycle executives are wary of a voluntary pact among more than 40 payers to reform prior authorization, Eric Musser, the NCQA’s vice president of federal affairs, sees the move as an encouraging sign of progress.

“While voluntary, it does feel like a time where we're seizing the moment to really revolutionize a process that's caused friction in the system for clinicians and for patients,” Musser says.

A Voluntary Pledge with a Mandatory Deadline

One reason for optimism is that the voluntary payer pledge aligns with the upcoming January 1, 2027 deadline from the CMS Interoperability and Prior Authorization Final Rule, which mandates the adoption of HL7 FHIR-based APIs for electronic PA.

This suggests payers intend to meet the federal mandate, a move that could finally allow the industry to abandon outdated modes of communication for PA requests.

“It shows a commitment of the health plans desire to make that 2027 deadline for electronic PA, and I think that that will be a huge step forward,” Musser says.

The Role of Quality Standards in Accountability

While providers worry about a lack of enforcement for the pact, NCQA’s utilization management standards – embedded in its Accreditation and Certification programs – prioritize clinician and patient experience and provide a structured framework for continuous quality improvement, which health plans are held accountable to. NCQA standards also already align with the CMS interoperability rule, according to Musser.

This means that for payers to comply with NCQA’s updated standards, they will need to build the infrastructure required by both the CMS mandate and their pledges.

“That's where NCQA plays a role,” Musser stated. CMS will also establish transparency requirements that plans will have to adhere to, such as posting denial rates.

A 'Spillover Effect' for the Broader Industry

Beyond smoothing some of the friction in prior authorization processes, Musser believes investment in this area will have a positive "spillover effect" throughout healthcare. The same standardized, digital clinical data flowing through FHIR APIs for PA can be leveraged to streamline other processes.

For Musser, the most exciting application is in the advancement of quality measurement.

Standardized data flowing through FHIR APIs “can be tied to more dynamic value-based care arrangements, but can also be used at the point of care to intervene and help with care coordination,” Musser explained. This will allow the healthcare professionals to “shine a light on where we can look for quality and improvements in improving health outcomes.”

From NCQA’s perspective, the AHIP announcement is more than just a pledge; it’s a significant moment of industry consensus, reinforced by federal mandate. For revenue cycle leaders, it signals not just a change in PA, but a shift toward a more digitized and interoperable healthcare system.