A group of major U.S. health insurers on June 20 announced a slate of voluntary reforms aimed at streamlining the prior-authorization process.
The move could eventually reduce administrative headaches for ambulatory surgery centers (ASCs), which have had to navigate an increasing volume of payer red tape in recent years.
The initiative, led by AHIP and the Blue Cross Blue Shield Association, includes commitments from Aetna, UnitedHealthcare, Humana, Cigna and dozens of other health plans. The pledge includes all the major payment arenas, too, from Medicare Advantage (MA) and commercial insurance to managed Medicaid.
AHIP is the large industry group for U.S. health insurers.
“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” AHIP President and CEO Mike Tuffin said in a statement. “Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system.”
The insurers supporting AHIP’s new prior-authorization pledge agreed to take six key actions:
– Standardizing electronic prior authorization, partly to support faster turn-around times, by Jan. 1, 2027
– Reducing the scope of claims subject to prior authorization, with demonstrated reductions by the start of next year
– Ensuring care continuity when patients change plans
– Better communicating explanations of prior-authorization determinations while including guidance on potential next steps, including appeals
– Expanding real-time responses
– Ensuring medical review of non-approved requests
If those promises turn into reality, it could translate to faster decisions, fewer prior-auth requirements and more seamless care transitions, areas that have long challenged ASCs and other providers.
“Thank you to the insurance companies for making these commitments today. Americans shouldn’t have to negotiate with their insurer to get the care they need,” U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr., said in a statement. “Pitting patients and their doctors against massive companies was not good for anyone. We are actively working with industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy and outpatient surgery.”
In 2023, Medicare Advantage plans processed 49.8 million prior-authorization requests, up from around 1.4 per enrollee in 2020 to 1.8 in 2023, according to Kaiser Family Foundation statistics.
Yet the pledge is not a mandate, Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz said during a June 20 press conference.
“This is not legislated,” he said. “This is an opportunity for the industry to show itself. Participation is voluntary, but by the fact that three-quarters of the patients in the country are already covered by participants in this pledge, it’s a good start, and the response has been overwhelming – gratifyingly so.”
What’s more, Oz suggested the actions would cut down on wasteful spending.
“We’re hopeful that we’ll actually save some money through this process, because we won’t be wasting the amount of money that is often spent unnecessarily when documents are sent back and forth, taking a precious time without changing the overall results,” he added.
Aetna, one of the largest payers backing the changes, said the move builds on its existing efforts.
“We support the industry’s commitments to streamline, simplify and reduce prior authorization,” Aetna President Steve Nelson said in a press release. “We will go beyond prior authorization, building a health care experience for people we serve and introducing solutions that improve navigation and advocacy for Aetna members.”
Aetna said more than 95% of its eligible prior authorizations are already approved within 24 hours, and it is bundling authorizations for conditions like cancer and musculoskeletal issues.
The reforms come after years of mounting pressure from providers, patients and lawmakers who have criticized prior authorization as an unnecessary barrier to care. ASCs, in particular, have voiced concern over delays in care and increased back-office burdens tied to prior authorization requirements.
Prior authorization and other administrative hurdles can delay patient care, especially if physicians aren’t able to carve out time to take care of approvals, Wes Battiste, CEO and founder of Destin Surgery Center, recently told ASC News.
Destin Surgery Center is a multi-speciality surgery center in Florida.
“It really comes back to the physicians, because the physicians are always the ones obtaining the approvals,” he said. “Are they willing to go the extra mile, have the peer-to-peer review, are they willing to do that to get the case to the ASC?”
