Marisol has been a utilization review since 2002. Ask her which plans go quiet after three o'clock on a Friday and she will tell you without checking anything.
She knows which one asks for records that were transmitted twice already. She knows which medical policy citation shows up on denials for a service the plan approved without comment just six months ago.
She has known all of it for years. Nobody has ever asked her for it in a form that could be used against the plan.
That is not a story about Marisol. It is a story about an organizational chart.
The clock is now a contract term, but almost no one watches it
The Interoperability and Prior Authorization final rule took full operational effect on January 1, 2026. Impacted plans, which include Medicare Advantage organizations, Medicaid and CHIP managed care entities, state fee-for-service programs, and qualified health plan issuers on the federal exchange, now have seven calendar days to decide a standard prior authorization request and seventy-two hours for an expedited one. Denials must carry a specific reason.
Denial rates went up anyway. Industry reporting through the first half of the year puts the year-over-year increase around thirty-one percent.
That combination should stop you. A federal deadline arrived, compliance became measurable, and the adverse outcomes got worse. That is not a clinical problem and it is not a documentation problem. It is an enforcement problem, and enforcement problems belong to contracting.
Here is the structural failure. The only person in your organization who holds the raw evidence that a plan blew a deadline is a utilization review nurse. She has the transmission timestamp, the request type, the deadline that applied, and the moment the answer came back or did not. That is a complete compliance record, generated dozens of times a day, by someone who reports through care management or quality and has never sat in a joint operating committee.
Meanwhile the person who negotiates the agreement walks into renewal with rate benchmarks, a payer scorecard built from claims data, and a general sense that authorizations have been difficult.
Difficult is not a contract term. One hundred and sixty-eight hours against a seventy-two hour standard is.
Why this keeps happening
Nobody designed this. It accumulated.
Utilization review was built as a clinical function because the work is clinical. The nurse's performance is measured on throughput, on avoidable days, on observation conversion, on the metrics that matter to care management leadership. Every one of those metrics is real. None of them capture whether the plan is meeting an obligation it agreed to in writing.
So the compliance evidence is generated as a byproduct and discarded as noise. It lives in the authorization system, in fax confirmations, in a portal that overwrites its own status field, and in Marisol's memory, which is the most accurate database in the building and the least admissible.
The accountability sits with leadership, not with her. She is doing the job as it was defined for her. What has not happened is anyone from contracting walking into care management and saying: the work you are already doing is evidence, and we need five fields of it.
This is the whole intervention. It is not a system purchase, it is not a new FTE, and it is not a process redesign. It is five fields captured on every authorization, structured so the output can be handed to a payer without translation.
One. Transmission timestamp and method. Date, time, and how the complete clinical package left your building. Complete matters. A partial submission resets the argument, so the field records the moment the last requested element went out, not the first.
Two. The standard that applied. Standard or expedited, the plan, the product line, and the decision deadline that governs that request under the contract and the applicable rule. Recording it at submission rather than reconstructing it later is what makes the file survive a challenge.
Three. Determination timestamp, or silence. When the answer arrived. If no answer arrived, the field records that explicitly, because a non-response is the strongest exception in the entire log and the easiest one to lose.
Four. The criterion cited. For every adverse determination, the specific policy provision the plan invoked, recorded as the plan stated it. Over a quarter this field alone will show you which criteria are being applied inconsistently, which is a different and more valuable argument than turnaround time.
Five. Disposition and dollars. Overturned, upheld, paid, written off, and the amount. This is the field that converts a compliance record into a finance conversation, which is the only conversation that changes a contract.
Five fields. Aggregate by plan and product line quarterly. What comes out is a compliance exception report, and that document does something no scorecard does. It puts a number on a promise the plan already made.
If this is landing for you, subscribe to Mastering Managed Care and follow me here: Kevin W. Barron, FHFMA, FACHE. This is about the work as it actually happens, not as it gets presented at conferences.
What the report is worth
Take it to the joint operating committee first, not to renewal. The JOC is where a plan can fix something quietly, and quiet fixes are cheaper for everyone than renewal fights.
Watch what happens in that room. The conversation you have been having for three years sounds like a complaint and gets absorbed as one. The same conversation, opened with a document showing that a plan missed its own contractual standard on a stated percentage of expedited requests across two quarters, is a different meeting. Nobody in it is talking about whether the problem is real.
Then bring the same report to renewal, where it does the second thing. It is the evidence base for every structural ask you have been unable to justify: the turnaround standard with a defined consequence, the overturn rate trigger, the audit right. Those asks fail without documentation. With four quarters of it, they become reasonable requests from a party demonstrating good faith.
And there is a third thing, which matters more than either. Marisol finds out her work counts. Fourteen years of pattern recognition stops being a private frustration and becomes an input the organization is built to use. Retention in utilization review is a chronic problem at every system I have worked in, and a meaningful part of it is that the job feels like absorbing a payer's behavior rather than doing anything about it.
The cost of leaving it where it is
Every quarter you do not capture this, a plan's non-compliance becomes uncollectible. Not disputed. Uncollectible, because the record that would have supported the dispute was never made. You are writing off enforceable claims as a cost of doing business and calling the result a denial rate.
At renewal you will ask for structural protection and the plan will ask what evidence you have. You will describe a pattern. They will note that patterns are difficult to verify. And the term you needed will trade away for something you can quantify, which will be rate, which resets in three years while the structural gap does not.
Do this
Ask your utilization review leadership one question this week: can you produce transmission timestamp, applicable standard, determination timestamp, criterion cited, and final dollars for every authorization from the last ninety days?
If the answer is no, you have found the gap. If the answer is yes, you have been sitting on your strongest negotiating document and have never opened it.
Your best evidence against a payer is already being generated. It is sitting in a queue, on the wrong floor, in front of someone with all of the knowledge who nobody thought to ask.
About the Author
Kevin W. Barron, MBA, FHFMA, FACHE is a nationally recognized healthcare contracting and payer relations executive with over 30 years of experience in healthcare finance. He is an author, speaker, and mentor to emerging leaders in healthcare finance. Follow Kevin on LinkedIn or subscribe to his weekly newsletter at https://www.KevinWatsonBarron.com
Disclaimer: This article is provided for general informational and educational purposes only. It reflects my personal views and observations based on professional experience in healthcare finance, managed care, payer relations, and revenue cycle operations. It should not be interpreted as legal, financial, regulatory, actuarial, or reimbursement advice. The content is not intended to represent the official position of my employer, any payer, provider, professional association, or other organization with which I may be affiliated. Readers should consult their own legal, financial, compliance, actuarial, or operational advisors before making decisions based on the issues discussed. Any references to payers, providers, regulations, market trends, or reimbursement practices are intended for discussion and education only and should not be construed as a statement about any specific contract, negotiation, patient matter, or confidential business arrangement.