State of Prior Authorization with Mark Fleming (Availity)

Mark Fleming is Senior Director of Prior Authorization, Interoperability, and Portal Solutions at Availity, a leading healthcare clearinghouse and data network. With over 25 years of experience in healthcare IT and revenue cycle management starting back when Epic had only 500 employees Mark is one of the industry’s foremost experts on modernizing the administrative friction between payers and providers.

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We discuss:

* Why a staggering two-thirds of prior authorizations are still stuck on manual faxes, phone calls, and isolated web portals.

* The massive structural shift behind the CMS-0057 mandate and how standardized FHIR APIs will force standard authorization timelines from weeks down to a strict 72-hour window.

* Moving from isolated transactions to real-time clinical transparency—letting providers query exact documentation and medical policy rules directly inside their EHR at the point of care.

* How digitizing clinical data allows modern AI platforms to parse requirements instantly, letting patients schedule sensitive procedures within days rather than waiting for weeks.

* The daunting scaling bottleneck of point-to-point connections, why the average health system routinely deals with 40 to 80 distinct payers each month, and why the industry must look toward centralized networks over customized developer builds.

My biggest takeaways from this conversation:

* The Stagnant State of Healthcare Administrative Friction: Despite immense technological progress in other areas of our daily lives, healthcare transactions remain stubbornly legacy. Currently, only about a third of prior authorization transactions utilize automated electronic X12 standards; the remaining two-thirds are split evenly between manual payer portals and decades-old faxes and phone calls.

* The Clinical Shift of CMS-0057: The incoming federal FHIR API standards mandate a massive operational pivot. Historically, providers gathered documentation and “threw it over the fence,” resulting in back-and-forth rejections because of highly specific medical policies. By introducing Coverage Requirements Discovery (CRD) and Documentation Templates and Rules (DTR) directly into the point-of-care workflow, providers will instantly know exactly what clinical information is required before a submission occurs.

* Real-Time Automated Care Approvals: Integrating real-time bi-directional FHIR streams with clinical decision platforms paves the way for immediate automated processing. By utilizing modern AI architectures to evaluate digital clinical datasets against explicit payer criteria, current production implementations (like Availity’s authAI tool) are already approving up to 78% of initial submissions within 60 seconds. This eliminates the safety buffer where providers schedule slots weeks out just to wait for a manual determination.

* The Network Scalability Challenge: Point-to-point custom integrations simply do not scale for provider ecosystems. Because an average mid-sized health system must route documentation to 40 distinct payers every single month and larger ones route to up to 80 building out separate point-to-point lines of communication is logistically unfeasible. Centralized networks must step in to act as translation and trust clearinghouses to standardize operations between varying EHR versions and complex payer architectures.

* The Cost-Burden Equivalence: Transitioning away from legacy administrative manual procedures can remove immense financial waste from the healthcare system. Current metrics show that a manual submission for a prior authorization costs an average of $9.00 per submission, whereas an fully electronic transaction utilizing standardized networks drops that cost to just $0.25.

Where to find Mark Fleming:

* LinkedIn: Mark Fleming on LinkedIn

* Website: Availity Official Portal

Referenced in the show:

* CMS-0057 (Interoperability and Prior Authorization Final Rule): CMS Official Summary

* CMS-0062 (Proposed Rule Expanding FHIR to Medications): Federal Register Rule Details

* HL7 Da Vinci Project & Burden Reduction Group: Da Vinci Framework Overview

* Trebuchet Project: Trebuchet Connectivity Infrastructure Initiative

* HealthClaw: Open Source Fire Data Quality Assessment Layer

* Epic Systems: Epic Corporate Page

* Athenahealth & Humana Joint Case Study: Reference Implementation Learnings

* Medical Group Management Association (MGMA) Survey: Prior Authorization Burden Metric Report

* TEFCA (Trusted Exchange Framework and Common Agreement): HealthIT.gov TEFCA Details

* FAST (FHIR At Scale Taskforce) Security Initiative: ONC FAST Security and Identity Working Group