Kirsten Peremore
In 2025, the US healthcare landscape is witnessing notable changes in authorization processes as a whole (both prior authorizations and patient authorization). Federal reforms aim to improve the prior authorization by requiring faster decision-making timelines for payers, such as CMS's requirement for urgent requests to be resolved within 72 hours starting in 2026.
States are also introducing stricter laws intended to protect patient rights. For example, Washington's My Health My Data Act requires granular consent for data sharing, while other states are implementing "gold card" programs that exempt high-performing providers from repetitive authorizations.
The challenges associated with prior authorization processes are echoed in ‘Influence of Prior Authorization Requirements on Provider Clinical Decision-Making,’ noting, “Almost two-thirds stated that they wait at least a day to hear from the insurance company on a PA request and slightly under one-third reported that they wait at least 3 business days…Given these consequences and the burden of PA, providers, pharmacists, policymakers, and other stakeholders have supported efforts to limit, standardize, and/or streamline PA processes.”
Patient authorizations as defined by HIPAA
Authorization refers to a specific, documented permission required from an individual before a covered entity can use or disclose their protected health information (PHI) for purposes beyond treatment, payment, or healthcare operations. A paper published in the Proceedings on Privacy Enhancing Technologies states, “Before a covered entity discloses data in a way that is not explicitly allowed, the Privacy Rule requires that the entity get the patient’s consent by presenting them with an 'authorization' that meets specific requirements.” The authorization is detailed and tailored to the situation, specifying the exact information to be disclosed, the recipient, and the intended purpose.
Legislative changes impacting patient authorization
Alignment of HIPAA with Part 2 regulations
The HHS Public Access Author Manuscript ‘Interpretation and Integration of the Federal Substance Use Privacy Protection Rule in Integrated Health Systems: A Qualitative Analysis’ provides that, “Since the initial passage and subsequent revisions of 42 CFR Part 2 in 1992, 2017, and 2018...there has been a gradual mainstreaming of SUD care into general medical settings and broad implementation of electronic health records (EHR).”
In 2024, the alignment of HIPAA with Part 2 regulations governing substance use disorder (SUD) records has influenced patient authorizations. The change simplifies compliance for entities subject to both HIPAA and Part 2 by allowing greater integration of SUD records into broader healthcare systems.
While this integration improves care coordination, it requires recipients of SUD-related PHI to attest that the information will not be used for prohibited purposes, like investigations into reproductive healthcare. The attestation process adds a layer of accountability that extends patient authorization powers.
2024 updates to the HIPAA Privacy Rule
The 2024 updates to the HIPAA Privacy Rule, which take effect in 2024 and are enforceable by December 2024, also include specific protections for reproductive health information. The legislative change follows the lack of protection as discussed in ‘Protecting the Privacy of Reproductive Health Information After the Fall of Roe v. Wade’, “Ultimately, broader information privacy laws are needed to fully protect patients and clinicians and facilities providing abortion services.”
The updated HIPAA Privacy Rule provides for this by requiring anyone requesting reproductive health information to provide an attestation confirming that they will not use the information in out-of-state judicial or administrative proceedings. Notices of privacy practices and additional authorization documents are subject to more intensive provisions in states where state laws do not contradict federal mandates. The process extends a patient's rights in these states to fully authorize and control the use of their PHI, including reproductive information.
The update is opposed with a Texas doctor, represented by Alliance Defending Freedom, filed a lawsuit against the U.S. Department of Health and Human Services (HHS) on October 21, 2024, challenging the recent HIPAA Privacy Rule aimed at protecting reproductive health and gender transition care records.
Legislative adjustments to the prior authorization process
The CMS Interoperability and Prior Authorization Final Rule
According to the American Medical Association, “In January, the Centers for Medicare & Medicaid Services (CMS) released a final rule that is expected to save physician practices an estimated $15 billion over 10 years by cutting patient care delays and electronically streamlining the process for physicians in the Medicare Advantage, State Medicaid and Children’s Health Insurance Program (CHIP), fee-for-service and managed-care programs, and other government-regulated health plans.”
The CMS Interoperability and Prior Authorization Final Rule is meant to automate prior authorization through electronic systems and improve data sharing between payers and providers. The rule does so by requiring that payers honor prior authorizations for a minimum period, even if patients change health plans, to minimize care delays. The Improving Seniors’ Timely Access to Care Act targets Medicare Advantage plans by requiring electronic prior authorization processes and setting specific timeframes for decision-making.
The American Medical Association approves of these changes, saying, "Prior authorization is overused, and existing processes present significant administrative and clinical concerns."
Decision-making progress in the authorization process
An advancement in the prior authorization process is tiered consent models, which allow patients to select varying levels of data-sharing permissions. For example, choosing whether their health information is used solely for treatment or extended to research purposes. According to a medical study published in Medicine, Health Care and Philosophy, “Tiered Consent is sometimes also referred to as Multi-Layered Consent. Typically, the options offered are formulated along the lines of issues supposed to be of individual or societal ethical relevance. For example, questions address types of disease the future research may be dealing with, options of sharing data with other institutions, and options regarding the return of information about incidental findings” Integrating these models into electronic systems, healthcare providers can streamline consent workflows and ensure compliance with evolving privacy regulations.
Another breakthrough is the use of virtual reality (VR) consent education, as exemplified by the Mayo Clinic's immersive decision-making simulations. VR technology allows patients to engage with medical information in a more interactive and comprehensible manner, improving their understanding of procedures and associated risks.
Blockchain consent ledgers further benefit patient authorizations by creating decentralized systems where individuals can directly manage permissions across health networks. According to Blockchain in Healthcare Today, “Blockchain consent ledgers further revolutionize patient authorizations by creating decentralized systems where individuals can directly manage permissions across health networks. Blockchain ensures the immutability and security of consent records, preventing unauthorized access or alterations. Patients can revoke or modify permissions in real-time, aligning data-sharing practices with their preferences. This technology addresses critical issues of interoperability and privacy, enabling seamless coordination among providers while safeguarding sensitive information.”
Blockchain ensures the immutability and security of consent records, preventing unauthorized access or alterations. Patients can revoke or modify permissions quickly, aligning data-sharing practices with their preferences.
The emerging challenges stemming from patient authorization processes
- Prior authorization workflows remain overwhelmingly manual, with 89% of providers attributing prior authorizations to contributing somewhat to physician burnout (AMA 2023). Staff spend 13+ hours weekly chasing approvals, diverting resources from patient care.
- Integration failures between EHRs and payer systems force manual data entry. Only 12% of prior auth transactions were fully electronic in 2018 (CAQH Index), worsening delays. Providers retrieve clinical data from EHRs and re-enter it into PA systems, introducing errors and wasting time.
- While CMS mandates electronic PA APIs for Medicare/Medicaid by 2026, states like Minnesota and Colorado require manual steps (e.g., phone/fax confirmations).
- 33% of physicians report PA delays caused adverse events; 9% linked denials to patient disability/death (AMA 2023).
What’s next
The ONC's HTI-1 final rule is a step forward, requiring developers to disclose data governance practices and mitigate risks associated with accuracy, bias, and safety. The push for transparency helps healthcare providers make informed decisions about the AI tools they integrate into clinical workflows.
Related: HIPAA Compliant Email: The Definitive Guide (2025 Update)
FAQs
How does a patient authorization differ from a general consent form?
Unlike general treatment consents, a patient authorization specifically governs the release of PHI for non-routine purposes (like third-party requests or research). It must include detailed descriptions of the information to be disclosed and the potential recipient.
Under what circumstances is patient authorization required, versus when is it exempt?
While disclosures for treatment, payment, or health care operations don’t require extra authorization, any use or disclosure outside these parameters (for example, marketing or non-routine research) requires a signed authorization. In emergency cases, however, patient authorizations may be bypassed if obtaining them would jeopardize timely care.
What elements must be included in a compliant patient authorization form?
- A clear description of the PHI to be disclosed
- The name or class of the third party receiving the information
- The purpose of the disclosure
- An expiration date or event that terminates the authorization
- A statement of the patient’s right to revoke the authorization in writing
How can a patient revoke an authorization, and what are the implications once revoked?
Patients may revoke their authorization at any time by submitting a written revocation.
