Insurers Commit to Streamlining Prior Authorization Process

Insurers, both major and minor nationwide, have declared a series of pledges aimed at reforming a significant obstacle in the patient experience: prior authorization.

Important actions include a commitment to decreasing the amount of services requiring prior authorization, with measurable enhancements by January 1, 2026. The initiatives aim to provide standardized and transparent systems that facilitate electronic prior authorization submissions, with an arrangement operational for plans and providers by January 1, 2027.

Approximately 50 insurers have committed to the promise, which includes all six of the top publicly listed health plans: UnitedHealthcare, Elevance Health, Cigna, Humana, Aetna and Centene. A multitude of Blue Cross Blue Shield plans are at the forefront of the program, which is supported by both the Blue Cross Blue Shield Association as well as AHIP.

The release indicates that the commitment covers many insurance marketplaces, including commercial strategies, Medicare Advantage, and Medicaid managed-care plans. Improvements to prior authorization standards are projected to impact over 250 million Americans.

AHIP CEO Mike Tuffin remarked that the healthcare system continues to be disjointed and weighed down by inefficient, outdated manual procedures, which contribute to dissatisfaction among both patients and healthcare providers. He noted that health plans are taking voluntary steps to create a smoother experience for patients and to allow providers to concentrate more on delivering care, all while contributing to the modernization of the overall system.

The insurance industry’s policies, especially prior authorization, have come under heightened scrutiny after the December 2024 assassination of then UnitedHealthcare CEO Brian Thompson. Following Thompson’s passing, several individuals expressed their grievances on social media over prevalent issues such as claim rejections, prior authorization, and provider networks.

The insurers also stated they intend to improve openness and communication about decisions. Patients will get clear and comprehensible explanations for decisions, including guidance on appeals and further actions if necessary.

Their goal is to implement these measures by January 1, 2026, in the completely insured and commercial sectors, while advocating for regulatory reforms that enable insurers to exhibit comparable transparency in other coverage categories, as stated in the release.

Other responsibilities include increasing the proportion of answers addressed in real time, with the objective that 80% of digital prior authorization requests will be fulfilled in real time by 2027. They reiterated that rejections citing a clinical explanation would be evaluated by medical specialists, a pre-existing requirement as stated in the release.

Furthermore, the insurers want to maintain continuity of treatment. If a patient changes insurance during treatment, they must maintain previous prior authorizations for comparable in-network therapies during a 90-day transition period.

The announcement also mentioned that progress towards these objectives would be monitored and reported to ensure accountability among the insurers.

Shawn Martin, EVP and CEO of the American Academy of Family Physicians, stated in the announcement that the company is optimistic about the commitments made by the health insurers.

Martin acknowledged that the commitment represented progress but emphasized that its true value would be judged by tangible improvements in the daily experiences of both patients and the physicians treating them. He added that they are eager to work alongside payers to ensure these initiatives bring about substantial and enduring enhancements in healthcare delivery.