Some of the nation’s largest insurance providers are pledging to make major reforms to the prior authorization process, a practice requiring insurance company sign-off for certain treatments that contributes to delayed or abandoned care for millions of Americans each year.
“Americans shouldn’t have to negotiate with their insurer to get the care they need,” Health and Human Services Secretary Robert F. Kennedy, Jr., said Monday, announcing the changes at a meeting of insurance groups in Washington. “Pitting patients and their doctors against massive companies was not good for anyone.”
The assembled companies pledged changes include working towards a standardized system of electronic prior authorization requests; reducing the number of treatments subject to prior authorization; honoring existing authorizations during insurance transitions; and expanding real-time responses to authorization requests, with a goal of real-time decisions for most requests by 2027.
“There's violence in the streets over these issues,” Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz said at the forum, an apparent reference to the fatal shooting of UnitedHealthcare CEO Brian Thompson in December. “This is not something that is a passively accepted reality anymore — Americans are upset about it.”
Present at the roundtable were representatives from major for-profit groups including Aetna, Blue Cross Blue Shield, the Centene Corporation, Cigna, Elevance Health, GuideWell, Highmark Health, Humana, Kaiser Permanente, and UnitedHealthcare.
AHIP, the health insurance industry’s largest lobbying group, praised the reforms.
“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” AHIP president Mike Tuffin said in a statement.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.”
Some were skeptical the voluntary reforms would ultimately give more Americans access to care, especially given the Trump administration’s attempts to add work requirements to Medicaid and projections showing the so-called “Big, Beautiful Bill” spending package could lead to $793 billion less Medicaid spending over the next 10 years with 10.3 million fewer people on Medicaid by 2034.
"We know from research that Medicaid work requirements produce losses of insurance without producing corresponding increases in employment," Miranda Yaver, health policy professor at the University of Pittsburgh and author of the forthcoming book Coverage Denied: How Health Insurers Drive Inequality in the United States, told NPR.
"I don't think it would be unfair to say that we're replacing one set of burdens with another,” she added.
A 2023 KFF survey found that prior authorization issues affect a wide variety of Americans, especially those with the most medical need.
Nearly one third of adults who had more than 10 visits with a physician over that year reported prior authorization problems, while adults taking at least one prescription medicine had more than double the rate of problems as those who don’t.
The American Medical Association describes the prior authorization system as “overused, costly, inefficient, opaque and responsible for patient care delays,” and its survey data indicates more than nine in 10 physicians report care delays while waiting for insurers to authorize necessary care, with 82 percent saying prior authorization can lead to treatment abandonment.
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