Dive Brief:
- Insurers are working to standardize how they vet requests for medical treatments and services, the latest in a series of commitments from the industry to pare back paperwork and make it easier for patients to get care.
- On Friday, major insurers led by industry groups AHIP and the Blue Cross Blue Shield Association announced they will align electronic data submission requirements for medical services commonly subject to prior authorization, such as orthopedic surgeries, CT scans and MRIs, beginning on Jan. 1.
- Prior authorizations will be standardized across commercial plans, Medicare and Medicaid, and additional services will be added over time, the insurance lobbies said.
Dive Insight:
Insurers say that prior authorization, which requires patients and their physicians to request coverage for a service before it’s provided, is an important tool for making sure that their members receive proper and cost-effective care.
Anecdotal reports from physicians suggest that payers have increased prior authorizations as they struggle to control ever-rising healthcare costs — even as insurers argue they’re paring back the unpopular preapprovals, in light of perennial complaints over the process.
Calls for prior authorization reform have caught the attention of the second Trump administration amid a growing animus against health insurers in Washington.
Last summer, the HHS secured a pledge from insurers to voluntarily streamline cumbersome prior authorizations — with the threat that regulators would do it for them if insurers didn’t comply.
The commitment includes the creation of a framework to standardize submissions for electronic prior authorizations.
Insurers say that prior authorization can be tricky because doctors often file physical paperwork that doesn’t always include all the needed information to review a patient’s medical plan. As a result, care can be delayed, if payers have to chase down providers to fill in the blanks, or denied altogether.
Standardizing electronic prior authorizations should help make the process faster and easier, AHIP said in its Friday release on the commitment.
Major insurers also touted their own progress towards aligning data submission requirements.
UnitedHealthcare, the largest private insurer in the U.S., said in a release on Friday that more than 50% of its prior authorization volumes are immediately able to be standardized, and that figure should exceed 70% by the end of this year.
Employer-sponsored insurance giant Cigna also expects to have more than 70% of its prior authorization volume standardized by the end of 2026.
Meanwhile, Aetna, the health insurance arm of retail pharmacy giant CVS, announced it had already standardized 88% of its prior authorization volume.
Insurers are also cutting some prior authorizations entirely as part of the larger pledge. Major insurers have reduced preapprovals by 11% so far, AHIP and the BCBSA said earlier this month.
Insurers covering more than 250 million U.S. patients are participating in the commitment.
“This is a meaningful step forward toward giving patients faster answers, more certainty, and fewer unnecessary delays in care. I applaud these efforts from a collection of the largest health plans across most market segments as momentum builds,” CMS Administrator Dr. Mehmet Oz posted on X on Friday.
Still, the commitment has some notable gaps. For one, it’s entirely voluntary, giving payers wiggle room when it comes to compliance. Many of the pledges are not tied to specific targets, including how many prior authorizations insurers will cut.
And hospitals and doctors say they’ve been burned before by insurers promising prior authorization reform.
For example, major payer and provider groups agreed on the need to improve prior authorizations in 2018. But eight years later, getting treatment approval is still a huge problem for providers.
In addition, efforts to winnow burdensome prior authorizations haven’t included prescription drugs, which make up a significant portion of requests. Though, the Trump administration is working to address that, proposing new deadlines to turn around prior authorizations decisions for drugs and standardizing the processes earlier this month.
