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Key takeaways:
Six reforms to streamline and reduce prior authorization will benefit 257 million Americans.
The pledge “will eliminate a lot” of causes behind delayed health care, HHS Secretary Robert F. Kennedy Jr. said.
WASHINGTON — HHS and health insurance plans announced commitments to streamline, simplify and reduce prior authorizations, ultimately lessening administrative burdens and improving access to care.
According to a press release from America’s Health Insurance Plans (AHIP), these commitments will be implemented across several insurance markets, “including for those with Commercial coverage, Medicare Advantage and Medicaid managed care consistent with state and federal regulations,” which will benefit 257 million Americans.
The pledge “will eliminate a lot” of causes behind delayed health care, HHS Secretary Robert F. Kennedy Jr. said. Image: Andrew (Drew) Rhoades/Healio
During a press conference, HHS Secretary Robert F. Kennedy Jr. said, “85% of Americans say they have had delays in health care because of prior authorization. We’re going to be able to eliminate a lot of those causes [because] of what we’re doing today.”
Six reforms will streamline prior authorization
According to the release, the 12 participating health insurance companies and dozens of health insurance plans have committed to:
standardize electronic prior authorization through the development of standardized data and submission requirements;
ensure continuity of care when patients change plans by honoring existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period;
reduce the scope of claims subject to prior authorization, with demonstrated reductions by Jan. 1, 2026;
affirm that all nonapproved requests based on clinical reasons will continue to be reviewed by medical professionals, a standard practice in place now;
expand the percentage of electronic prior authorization approvals answered in real-time to at least 80% by 2027 along with the adoption of application programming interfaces across all insurance markets; and
enhance communication and transparency by having health plans “provide clear, easy-to-understand explanations of prior authorization determinations.”
The goal for the initiative’s framework is to be operational and available to plans and providers by Jan. 1, 2027. Kennedy Jr. said HHS has established “deliverables … metrics and deadlines” for the reforms.
Among the health insurance companies currently included in the industry pledge are Aetna Inc., Blue Cross Blue Shield Association, Kaiser Permanente and UnitedHealthcare, an HHS press release said.
“We expect many other companies to also join,” Kennedy Jr. said.
Health care inaccessibility remains a pressing public health issue, with a recent survey indicating that more than one in three Americans could not access quality health care if they needed it today.
The process of prior authorizations similarly continues to pose difficulties for health care providers. Experts previously told Healio that recent attempts to improve the process, like CMS finalizing the Interoperability and Prior Authorization Final Rule, were positive for health care professionals but that more needed to be done.
Pledge is not a mandate but an ‘opportunity’
The release said that the commitments will result in more evidence-based care and faster and greater direct access to appropriate treatments for patients, as well as fewer burdens and a “more efficient and transparent process overall” for health care professionals.
CMS Administrator Mehmet Oz, MD, MBA, said during the press conference that the pledge addresses many “timely” issues in the prior authorization process, such as inefficiency and a lack of transparency and accountability, and “will deliver what is needed by the right way.”
“Patients should not be waiting because bureaucratic hurdles are blocking their critical treatment,” he said. “If done correctly, ongoing procedures for medications and alike will create a seamless relationship between patients and providers.”
Oz previously called prior authorization a “pox on the system” during his U.S. Senate Committee on Finance hearing in March and underlined the need for a mechanism “to confirm that procedures are worthwhile.”
Oz said that the pledge is not mandate but an “opportunity … for the industry to show itself.”
However, “we have the ability through the rules process to enforce preauthorization if necessary,” he added.
Reactions from medical community
AMA President Bobby Mukkamala, MD, said in a statement he is “optimistic” that the companies’ pledge to enforce the reforms “will provide more patients and physicians with relief.”
“The proposals announced today would help right-size and streamline a process that is harming our patients daily,” he said. “However, patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions to bring immediate and meaningful changes, break down unnecessary roadblocks, and keep medical decisions between patients and physicians.”
Colin Banas, MD, MSHA, chief medical officer at DrFirst, told Healio that “the clinician and hopeful in me thinks, ‘Wow, this is a step in the right direction. They’re finally getting the message. Perhaps they will accelerate the change that is so needed in the prior authorization-patient care realm.’”
“The cynic in me says we’ve been down this road before,” he said.
It appears medical prescriptions may not be affected by these reforms, Banas added.
Rather, “I think we’re talking about prior authorizations for physical therapy and medical treatments like surgeries or procedures,” he said. “While all sides of the prior authorization coin are painful, I think the prescription pain is especially relevant.”
The fact that the initiative is a pledge as opposed to a mandate raises additional questions.
“Where’s the consequences? What are the parameters? Who’s measuring and who’s enforcing?” Banas asked. “A pledge is only as good as the one making the commitment.”
