Insurance companies vow to fix prior authorization process…again

Insurance industry promises prior authorization reform again: ©Piter2121

AHIP, the industry trade group for health insurance plans, announced a series of commitments to streamline the prior authorization process, which they say is necessary to “ensure their members’ care is safe, effective, evidence-based and affordable.”

According to the group, these new actions are focused on connecting patients more quickly to care while minimizing administrative burdens for providers.

The participating health plans commit to:

• Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions for electronic prior authorization. This commitment includes the development of standardized data and submission requirements (using FHIR APIs) that will support seamless, streamlined processes and faster turn-around times. The goal is for the new framework to be operational and available to plans and providers by Jan. 1, 2027.
• Reducing the Scope of Claims Subject to Prior Authorization. Individual plans will commit to specific reductions to medical prior authorization as appropriate for the local market each plan serves, with demonstrated reductions by Jan. 1, 2026.
• Ensuring Continuity of Care When Patients Change Plans. Beginning Jan. 1, 2026, when a patient changes insurance companies during a course of treatment, the new plan will honor existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions.
• Enhancing Communication and Transparency on Determinations. Health plans will provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps. These changes will be operational for fully insured and commercial coverage by Jan. 1, 2026, with a focus on supporting regulatory changes for expansion to additional coverage types.
• Expanding Real-Time Responses. In 2027, at least 80% of electronic prior authorization approvals (with all needed clinical documentation) will be answered in real-time. This commitment includes adoption of FHIR APIs across all markets to further accelerate real-time responses.
• Ensuring Medical Review of Non-Approved Requests. Participating health plans affirm that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals—a standard already in place. This commitment is in effect now.

These commitments are being implemented across insurance markets, including for those with commercial coverage, Medicare Advantage and Medicaid managed care consistent with state and federal regulations, and will affect 257 million Americans, according to AHIP.

AHIP says that for providers, these commitments will streamline prior authorization workflows, allowing for a more efficient and transparent process overall, while ensuring evidence-based care for their patients.

“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.

This is not the first time that AHIP members have committed to prior authorization reform. In 2018, a consensus group made up of all the major medical associations and AHIP agreed on several principles on how prior authorizations should be handled and how they could be improved. But years later, there was little progress to show for all the promises made, so physicians are hopeful, yet skeptical regarding the recent announcement.

“We are encouraged by this collective commitment to reform prior authorization practices. Physicians have long advocated for reforms that help ensure that patients receive timely, medically necessary care and reduce administrative burden—including the elimination of unnecessary prior authorizations,” said Shawn Martin, executive vice president and CEO of the American Academy of Family Physicians. “While this commitment is a step in the right direction, we will ultimately measure its impact by real changes in the day-to-day experiences of patients and the physicians who care for them. We look forward to collaborating with payers to ensure these efforts lead to meaningful and lasting improvements in patient care.”

The Medical Group Management Association is likewise taking a wait-and-see approach. "While we are encouraged by today's announcement from health plans on prior authorization, much of what insurers intend to do has already been mandated by CMS for their Medicare Advantage and Medicaid managed care plans along with similar adoption dates," said Anders Gilberg, senior vice president, government affairs, MGMA. "It makes sense for them to implement changes across commercial products as well. MGMA joined a consensus statement with provider groups and health plans in 2018 that had similar agreed-upon principles for improving prior authorization, yet year-after-year we continue to hear from physician practices that it is their number one administrative burden. Seven years after the consensus statement and several CMS final rules later, health insurers appear to finally be taking steps toward implementation. We look forward to receiving more details about the initiative and working towards reducing the overall volume and burden of prior authorization requirements."

HHS officials applauded the industry commitment.

“Pitting patients and their doctors against massive companies was not good for anyone,” said HHS Secretary Robert F. Kennedy Jr. “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.”

“These commitments represent a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care,” said CMS Administrator Mehmet Oz. “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.”

According to AHIP, progress toward these announced goals will be tracked and reported.

Here is the list of health care plans agreeing to work toward the goals:

AmeriHealth Caritas

Arkansas Blue Cross and Blue Shield

Blue Cross of Idaho

Blue Cross Blue Shield of Alabama

Blue Cross Blue Shield of Arizona

Blue Cross and Blue Shield of Hawaii

Blue Cross and Blue Shield of Kansas

Blue Cross and Blue Shield of Kansas City

Blue Cross and Blue Shield of Louisiana

Blue Cross Blue Shield of Massachusetts

Blue Cross Blue Shield of Michigan

Blue Cross and Blue Shield of Minnesota

Blue Cross and Blue Shield of Nebraska

Blue Cross and Blue Shield of North Carolina

Blue Cross Blue Shield of North Dakota

Blue Cross & Blue Shield of Rhode Island

Blue Cross Blue Shield of South Carolina

BlueCross BlueShield of Tennessee

Blue Cross Blue Shield of Wyoming

Blue Shield of California

Capital Blue Cross

Capital District Physicians' Health Plan, Inc. (CDPHP)

CareFirst BlueCross BlueShield

Centene

The Cigna Group

CVS Health Aetna

Elevance Health

Excellus Blue Cross Blue Shield

Geisinger Health Plan

GuideWell Mutual Holding Corporation

Health Care Service Corporation

Healthfirst (New York)

Highmark Inc.

Horizon Blue Cross Blue Shield of New Jersey

Humana

Independence Blue Cross

Independent Health

Kaiser Permanente

L.A. Care Health Plan

Molina Healthcare

Neighborhood Health Plan of Rhode Island

Point32Health

Premera Blue Cross

Regence BlueShield, Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, Asuris Northwest Health, BridgeSpan Health

SCAN Health Plan

SummaCare

UnitedHealthcare

Wellmark Blue Cross and Blue Shield