Prior authorization has lengthy been a sticking level between payers and suppliers, with payers arguing that it’s mandatory to manage prices and be certain that care is medically mandatory and suppliers arguing that it creates administrative burden and delays care.
No matter who’s proper on this debate, it’s clear that the observe is in determined want of enchancment. That’s why in June, greater than 50 well being plans — akin to UnitedHealthcare, Aetna, Cigna and several other Blues plans — made a series of commitments in partnership with the Facilities for Medicare and Medicaid Providers to simplify prior authorization, together with offering extra clear explanations of prior authorization determinations, growing turnaround instances for determinations and making certain continuity of care when sufferers change plans. A number of of those commitments will go into place in 2026, whereas others will take impact in 2027.
“We’re making significant progress on bettering the prior authorization course of. … With many enhancements going reside in January, we stay dedicated to streamlining processes and decreasing the scope of necessities to enhance the expertise for sufferers and suppliers,” a Blue Cross Blue Protect Affiliation consultant who declined to be named informed MedCity Information.
Nonetheless, the query stays of whether or not these commitments can be sufficient for suppliers, who typically appear cautiously optimistic concerning the commitments.
“Any step towards decreasing prior authorization is welcome, and household physicians have been asking for aid for years,” stated Dr. Jen Brull, board chair of the American Academy of Household Physicians. “From the place we sit in examination rooms, commitments alone aren’t enough. Prior authorization nonetheless eats up an unlimited period of time and causes actual delays in care; almost 90% of physicians say it’s extraordinarily burdensome. Till we see significant adjustments that truly scale back paperwork and pace up approvals, sufferers and physicians will proceed to really feel the pressure.”
Past these commitments, 2025 has seen further developments within the prior authorization panorama, together with the introduction of the WISeR Model, which extends prior authorization necessities into conventional Medicare. In 2026, specialists may even be watching out for developments within the Improving Seniors’ Timely Access to Care Act, which might streamline prior authorization in Medicare Benefit.
What are the commitments in 2026?
In accordance with AHIP’s announcement in June, the commitments going into impact in 2026 are:
- Lowering the scope of claims topic to prior authorization: The insurers will scale back prior authorization necessities for sure claims, which is able to rely available on the market every plan serves. These reductions are anticipated to start out January 1, 2026.
- Making certain continuity of care when sufferers change plans: When sufferers change insurance policy throughout remedy, their new insurer should honor current prior authorizations for related in-network providers for 90 days to make sure continuity of care and stop delays. This can start January 1, 2026.
- Bettering communication and transparency on determinations: The insurers pledge to offer clear explanations of prior authorization determinations, in addition to data on appeals. This can be obtainable for totally insured and industrial protection by January 1, 2026.
In 2027, payers will deal with standardizing digital prior authorization and increasing real-time responses. Insurers anticipate that at the least 80% of digital prior authorization approvals can be answered in real-time.
In whole, 53 plans signed all of those commitments, together with the most important names on the planet of healthcare insurance coverage: UnitedHealthcare, Elevance Well being, Aetna, Cigna, Kaiser Permanente, Centene, Humana, Highmark and several other Blues plans.
AHIP Spokesperson Chris Bond informed MedCity Information that progress can be tracked and reported publicly. The group anticipates that the primary report will come within the spring of 2026.
A number of payers informed MedCity Information that they’re on observe for the commitments in 2026. Dr. Muhannad Hammash, company vice chairman of medical coverage at SCAN Well being Plan, stated the nonprofit Medicare Benefit insurer has been working intently with its supplier companions to make sure readiness, together with internet hosting an October summit to overview the commitments and holding one-on-one conferences with particular person teams to assist them perceive and put together for the adjustments.
That stated, there are challenges to getting these commitments so as. For instance, assembly the 2027 dedication for digital prior authorization would require a considerable effort to assist suppliers that at present lack the know-how infrastructure and sources wanted to submit prior authorization requests electronically.
“A few of these applied sciences are costly, particularly for smaller teams,” Hammash stated. “That’s one of many challenges we’ve to look into and see what’s one of the simplest ways we will work with these suppliers in resolving these points, as a result of we’ve to maneuver from the standard approach of paperwork and faxes to utilizing know-how that may assist us pace up the method.”
An government at Blue Protect of California echoed the necessity for extra superior know-how to make sure these commitments work.
“Well being plans might want to leverage their inside intelligence about members, insurance policies, advantages, and networks to facilitate automated approvals at scale,” stated Dr. Laurine Tibaldi, vice chairman of medical administration at Blue Protect of California. “We are going to hopefully see extra suppliers improve their use of know-how to speak with well being plans wherever doable – rather than faxes or telephone calls. Extra real-time communications between well being plans and suppliers will assist sufferers get care sooner and scale back stress for everybody concerned.”
Aetna President Steve Nelson informed MedCity Information that the insurer is working to meet these commitments and shoot even greater. For instance, it announced in December that it’s bundling medical procedures and pharmaceutical drugs into one prior authorization. Beforehand, suppliers needed to submit two separate prior authorizations for medical procedures and associated drugs. As well as, the insurer is engaged on bringing extra transparency into the method.
“One of many frustrations about prior authorization is you don’t know the place you might be within the course of,” Nelson stated in an interview. “We’ve added capabilities in a digital app so now you can know the place you might be within the course of. Is it pending? Has it been denied? What’s the subsequent step? Has it been permitted? What’s happening with it?”
Will this be sufficient for suppliers?
Whereas physicians are typically optimistic about these commitments, it goes with out saying that there’s just a little skepticism as properly.
To carry payers accountable, Brull stated suppliers ought to be sure that to doc delays, denials and inconsistencies and convey these considerations to lawmakers.
A Medicare coverage knowledgeable at consulting agency McDermott+ — Lynn Nonnemaker — famous that the skepticism amongst suppliers is each “acceptable and wholesome,” and this skepticism will play a task in making certain that plans comply with by means of. She added that CMS Administrator Dr. Mehmet Oz has stated that the company is ready to behave if plans don’t comply with by means of.
“Actually, CMS might go additional in proscribing plans’ use of prior authorization,” she stated in an interview. “One essential factor that CMS can do is function a convener in serving to result in extra standardization of the programs and processes that plans use and the way in which that suppliers work together with them.”
Though the onus is on the insurers to hold out these commitments, suppliers may take their very own steps to enhance prior authorization, Nonnemaker’s colleague famous.
“It takes two to tango,” stated Jeffrey Davis, a director at McDermott+. “So if the payers need to automate the method, which means the supplier aspect should have the know-how in place, the programs in place, to deal with these automated transactions. Suppliers have to purchase into this too and arrange their programs. Payers can do all they need on their aspect, but when the suppliers don’t take part, there’s not going to be a seamless prior authorization course of.”
An government at GuideHealth, a tech-enabled value-based care providers firm, echoed this.
“Suppliers can enhance outcomes by standardizing submissions, utilizing structured scientific knowledge, and aligning with evidence-based pathways in collaboration with payers,” stated Sanjay Doddamani, founder and CEO of GuideHealth, in an e-mail. “Treating prior auth as a shared scientific and operational workflow, slightly than a downstream administrative activity, is essential to decreasing friction.”
Past these commitments, Brull is hopeful that there can be motion on the Seniors’ Well timed Entry to Care Act, which might streamline prior authorization in Medicare Benefit.
“The Home has already handed it as soon as, and we’re working arduous to get it throughout the end line,” she stated. “On the finish of the day, prior authorization ought to by no means stand between a affected person and well timed care, and physicians ought to be capable of deal with caring for sufferers, not paperwork.”
This can be a burden felt by most physicians, as 94% reported in an American Medical Affiliation survey that prior authorization causes main delays in mandatory care. There’s an financial cause for decreasing prior authorization as properly. In accordance with a study printed in Well being Affairs, drug prior authorization prices $93.3 billion yearly, together with $6 billion for payers, $24.8 billion for producers, $26.7 billion for physicians and $35.8 billion for sufferers.
Given the burden of prior authorization, Brull can also be involved about some strikes that CMS is taking that may have a worrying impression. She stated that new innovation fashions might “reintroduce prior authorization underneath totally different names or mechanisms, which suggests practices have to remain vigilant simply to maintain affected person care transferring.”
As an illustration, in June, CMS Innovation Middle launched the WISeR mannequin (Wasteful and Inappropriate Service Discount Mannequin), that brings a previous authorization course of into conventional Medicare in an effort to scale back “fraud, waste and abuse.” That is regarding to Brull as conventional Medicare has “lengthy been free from these hurdles.” This might gradual look after seniors and add extra administrative challenges to practices, she stated.
Photograph: Piotrekswat, Getty Photos
