Health insurers, including Humana, Elevance and CVS Health, have committed to a number of actions meant to simplify and reduce prior authorization, with a focus on connecting patients to care more quickly and reducing providers' administrative burdens.
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 stand to benefit about 257 million Americans, according to AHIP.
Insurers are promising faster and more direct access to appropriate treatments for patients, and for providers, more efficient and transparent prior authorization workflows.
"The healthcare system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike," said AHIP President and CEO Mike Tuffin. "This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience."
Health and Human Services Secretary Robert F. Kennedy Jr. and Dr. Mehmet Oz, administrator for the Centers for Medicare and Medicaid Services, are scheduled to hold a press conference on the initiative today at 2:45 p.m.
WHAT'S THE IMPACT
Participating health plans have signaled that they're 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 streamlined processes and faster turnaround times. The goal is to have a new framework up and running by Jan. 1, 2027.
Individual plans will also commit to specific medical prior authorization reductions, as appropriate for each plan's local market, with demonstrable results by Jan. 1, 2026.
According to AHIP, by 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.
The participating health plans said that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals, as they are now.
A full list of participating health plans and additional information can be found here.
THE LARGER TREND
Lawmakers in the House of Representatives rolled out a bipartisan bill in March that would task board-certified specialists with determining the medical need of prior authorization requests.
The Reducing Medically Unnecessary Delays in Care Act would reform the practice of prior authorization in Medicare and Medicare Advantage by requiring that board-certified physicians in the same specialty are the ones making those decisions.
It would also direct Medicare, Medicare Advantage and Medicare Part D plans to comply with requirements that restrictions must be based on medical necessity and written clinical criteria, as well as additional transparency obligations.
A June 2024 survey from the American Medical Association found the prior authorization process continues to have a "devastating" effect on patient outcomes, physician burnout and employee productivity.
In addition to negatively impacting care delivery and frustrating physicians, PA is also leading to unnecessary spending in the form of additional office visits, unanticipated hospital stays and patients regularly paying out-of-pocket for care, results showed.
In the AMA's annual survey of 1,000 practicing physicians, 94% reported that PA resulted in delays to care, while 78% reported that it can sometimes lead to the abandonment of treatment altogether.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.