Health Insurers Commit to Streamlining Prior Authorization Process

Following the killing of a top health insurance executive that sparked anger over medical care denials, the industry has announced that it will take action to streamline and simplify the prior authorization process. Dozens of health insurers covering 257 million people, including UnitedHealthcare, CVS Health's Aetna, Cigna, Humana, Elevance Health, and Kaiser Permanente, have committed to six steps to make it easier for patients to get appropriate care. These measures include implementing a common electronic prior authorization process, reducing the scope of claims subject to preapproval, and ensuring that plans honor existing prior authorizations for 90 days for patients who change carriers during treatment.

Key Takeaways:

• The participating health insurers have promised to implement a common electronic prior authorization process, which will help speed the decision timeline and reduce administrative burdens for providers.
• The goal is for the new framework to be in place by January 1, 2027, and will initially apply to those with commercial insurance.
• Insurers will reduce the scope of claims subject to preapproval by the start of next year, and ensure that plans honor existing prior authorizations for 90 days for patients who change carriers during treatment.
• Insurers will expand the share of electronic prior authorization approvals answered in real-time to at least 80% in 2027, if all needed clinical documentation is submitted.
• The industry will work with regulators to expand these measures to other coverage types, including Medicare Advantage and Medicaid-managed care.
• Insurers will provide clear explanations of their determinations, including information about appeals, and will continue to review denied requests by medical professionals.
• The commitments will be posted on a dashboard that will allow the agency, patients, providers, and others to assess progress.

Statistics:

• 257 million people will be covered by the participating health insurers (CNN)
• The new prior authorization framework will be implemented by January 1, 2027
• Insurers will reduce the scope of claims subject to preapproval by the start of next year
• The share of electronic prior authorization approvals answered in real-time will be at least 80% in 2027
• Fewer than 12% of denied prior authorization requests were appealed in Medicare Advantage in 2023 (KFF)
• Nearly 82% of appeals resulted in the denials being partially or fully reversed in Medicare Advantage in 2023 (KFF)

Sources:

• CNN: "Health insurers commit to streamlining prior authorization process"
• Blue Cross Blue Shield Association: "Commitments to Streamline and Simplify the Prior Authorization Process"
• AHIP: "Industry Pledge to Improve Prior Authorization Process"