The New Prior Authorization Scorecards: How to Compare Payers Using Their Own Data

Many health plans now have to show the public how their prior-authorization processes perform.

Under the CMS Interoperability and Prior Authorization Final Rule, affected payers must publish a standard set of prior-authorization metrics every year. The first reports cover calendar-year 2025 activity and were due in 2026.

These reports give specialty practices a useful starting point. Combined with the practice’s own denial and authorization data, they can reveal which payers create the most friction, where appeals are worth pursuing, and which workflows need attention.

What payers must disclose

The requirement applies to Medicare Advantage organizations, state Medicaid and CHIP programs, Medicaid and CHIP managed-care plans, and qualified health plan issuers on federally facilitated exchanges.

For medical items and services subject to prior authorization, affected payers must publicly report metrics that include:

• The items and services that require prior authorization.

• The percentage of standard requests approved and denied.

• The percentage of standard requests approved after appeal.

• Approval rates for requests whose review period was extended.

• Approval and denial rates for expedited requests.

• Average and median decision times for standard requests.

• Average and median decision times for expedited requests.

Beginning in 2026, affected payers must also provide a specific reason when they deny a prior-authorization request for a medical item or service covered by the rule.

Build a payer scorecard for your practice

Use the public numbers as a baseline, then compare them with the practice’s own experience.

Start with the five or ten payers responsible for most of your volume. Capture their published approval, denial, appeal, and turnaround-time figures in one consistent view. Then add internal measures such as:

• Authorization volume by service and location.

• Requests for additional information.

• Time from submission to decision.

• Initial non-affirmation or denial rate.

• Appeal volume and appeal success rate.

• Procedures delayed or rescheduled while approval was pending.

• Staff time spent obtaining records or responding to the payer.

The comparison can expose patterns that an aggregate denial rate misses. A payer may report a low overall denial percentage while one specialty service repeatedly triggers requests for more information. Another payer may decide quickly but create rework because its documentation requirements are missing from the practice’s intake process.

Use the data to choose the right response

Different payer problems call for different responses.

If a high share of requests are missing the same evidence, update the note template or authorization checklist. If turnaround time is the main issue, submit earlier and build escalation rules around the payer’s published deadlines. If appeal success is high, make sure staff can identify and pursue the denials with the strongest clinical support. If one location performs materially worse than another, audit the workflow before blaming the payer.

The same information can strengthen payer conversations. Practice leaders can identify the affected services, the internal rate, the payer’s published baseline, and the financial or scheduling impact.

Know the limits of the scorecards

CMS allows these metrics to be published in aggregate. They may hide the variation by specialty, procedure, market, or reviewer that matters most to an individual practice. Teams should still review current payer policies and coverage criteria.

Public metrics describe the payer’s overall performance. The practice’s chart, claim, authorization, and denial data show what happens locally. Both views are needed.

Turn transparency into leverage

The new reporting rules give practice leaders evidence for evaluating payer performance. Pairing public metrics with consistent pre-bill and authorization review can uncover preventable friction, focus appeal resources, and improve payer discussions.

The value comes from using the data in day-to-day authorization and pre-bill work.

See what your charts are hiding

Syntra reviews charts and charges before submission, helping specialty practices identify documentation gaps, coding risk, and payer-specific patterns across every claim.