- Health insurers agree to six reforms that should cut red tape and make getting care easier.
- Prior authorization for some procedures to be removed and the process simplified.
- HHS officials hail the voluntary agreement, but hint that regulation is a possibility, too.
Major health insurers have agreed to six reforms that should reduce both wait times and barriers that stand between patients and procedures or services their health care providers say they need.
Monday, during an industry discussion convened by the U.S. Department of Health and Human Services, insurers who provide about 80% of insurance coverage through Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace and commercial plans agreed to voluntarily make significant changes, including reducing and in some cases eliminating prior authorizations.
The reforms, according to a bulletin from HHS, include:
- Reducing the number of medical services that require prior authorization, “with demonstrated reductions” by 2026.
- Honoring existing prior authorizations for a 90-day transition period if someone changes insurance, starting in 2026.
- Being more forthcoming about authorization decisions and appeals, as well as providing guidance on next steps by 2026.
- Speeding up the prior authorization process by 2027, with 80% done in “real time.”
- Having medical experts review clinical denials, which is supposed to already be how it’s done.
- Standardizing electronic prior authorization submissions to reduce the burden on health care providers and cut waiting time, a change due by January 2027.
U.S. Health and Human Services Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services Administrator Dr. Mehmet Oz met with the industry leaders then released the announcement outlining the pledge. They said the insurers have agreed to cut red tape, speed up care decisions and improve transparency for patients and providers.
Kennedy said in a news conference that it is expected to become easier for patients to get prior authorization for common services like imaging, physical therapy and outpatient surgery.
Barriers to care
Prior authorizations were intended to ensure that expensive care wasn’t being wasted, but would benefit those who need certain procedures or services. Critics, however, have said that denying prior authorization requests has sometimes been nonsensical and is a very common practice.
Physicians have been among the most critical. For instance, a 2024 survey by the American Medical Association of physicians regarding prior authorization found 93% said prior authorizations had delayed needed care for a patient. And 82% said they’d seen occasions when the prior authorization process led to abandoning a recommended course of treatment.
“Almost 1 in 3 (31%) physicians report that (prior authorization) criteria are rarely or never evidence-based,” per the survey findings.
A quarter of the physicians reported at least one of their patients suffered serious adverse effects because of the prior authorization process. They also said their practice spends about 13 hours a week working on obtaining prior authorizations. Many report having a staff member whose main job is handling prior authorizations.
As The Guardian reported, “Prior authorization is an insurance company practice that is both common and abhorred. There are whole social media accounts devoted to egregious examples of it, campaigns for change built around it, and, in Oz’s words, there is ‘violence in the streets’ over prior authorization — an allusion to the broad daylight killing of an insurance company CEO.
During a press conference on the pledge, Oz said that 85% of Americans or their loved ones had care delayed because of the practice.
Good for patients and providers
An estimated 257 million Americans will benefit from the changes, according to AHIP, a trade association for health insurance providers.
Kennedy hailed the pledge, noting that “pitting patients and their doctors against massive companies was not good for anyone. We are actively working with industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy and outpatient surgery.”
Oz called the pledge a “step in the right direction toward restoring trust, easing burdens on providers and helping patients receive timely, evidence-based care.” He added, “We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first.”
The department reported that the private-sector reforms pair well with CMS regulatory efforts, but added that CMS “reserves the right to pursue additional regulatory actions if necessary.”
Praise from health insurers
AHIP reported that patients will see “faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system.” Providers will find it easier to achieve prior authorizations, reducing their time and effort to secure care they believe their patients need.
“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system,” said AHIP president and CEO Mike Tuffin, in the written statement.
Kim Keck, president and CEO of the Blue Cross Blue Shield Association, called it “an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience.”
Per the release, the companies at the discussion included Aetna, Inc., AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Inc., Kaiser Permanente and UnitedHealthcare.
It’s too soon to say whether other insurance providers will follow suit. But the industry organization’s release said that a full list of health plans that have agreed and additional information are available at: www.ahip.org/supportingpatients and https://www.bcbs.com/ImprovingPA.