Obtaining prior authorization for a medical test or procedure can be one of the most frustrating and time-consuming aspects of health care. Now, the Trump administration is looking to streamline the process.
Health Secretary Robert F. Kennedy Jr. announced Monday, June 23, that some of the country’s largest insurers have pledged to take steps to make the process of getting prior authorization more efficient. Those insurers include Blue Cross Blue Shield Association, Cigna, Elevance Health, GuideWell, Humana, Kaiser Permanente and UnitedHealthcare.
What is prior authorization?
Prior authorization is a process where health plans require health care providers to get approval before they can provide certain medical services or medications.
Critics say the process creates too many roadblocks, often forcing patients to wait days or weeks to get the care they need –– if it’s even approved at all.
The practice came back into the spotlight late last year when UnitedHealthcare’s CEO was fatally shot. Authorities say the suspected shooter targeted Brian Thompson as part of a broader grievance against the health care industry.
Not the first attempt
This is not the first time health insurance companies have announced their intention to address issues with the prior authorization system. In 2018 and 2023, health insurance companies made commitments to reform the practice, but they never followed through.
Both Kennedy and Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services (CMS), acknowledged those failed attempts on Monday.
When asked what’s different this time around, Dr. Oz said, “I mean, there’s violence in the streets over these issues. This is not something that is a passively accepted reality anymore. Americans are upset about it.”
A common issue
A 2023 survey by the Kaiser Family Foundation (KFF) found that 6 in 10 insured adults experience problems when they use their insurance, including delays and denials of prior authorization.
The survey found 16% of insured adults experienced prior authorization issues. It also found that those enrolled in Medicaid or utilizing more health care services were among those more likely to face problems with prior authorization.
Unbiased. Straight Facts.TM
About 1 in 6 insured adults experience prior authorization problems.
KFF also found that those who experienced prior authorization problems were much more likely to encounter other problems using their coverage, like reaching the limit on covered services, not being able to find or access an in-network provider, and denied claims.
How will the prior authorization process be streamlined?
The Department of Health and Human Services and America’s Health Insurance Plans (AHIP), a health insurance industry trade group, say there are six key parts of the insurers’ pledge:
- Standardize how electronic prior authorizations are submitted.
- Reduce the number of medical services that require prior authorization.
- Honor existing authorizations if patients change insurance plans in the middle of treatment.
- Be more transparent and enhance communication about authorization decisions and appeals.
- Minimize delays with real-time approvals for most requests.
- Ensure medical professionals review all clinical denials.
The changes will be implemented across private insurance, Medicare Advantage and Medicaid.
AHIP said the changes could benefit 257 million people in the United States.
When will we see the changes?
Federal health officials say the prior authorization process will be significantly better for health care providers and patients by the end of this year, but they did not specify how.
According to AHIP, insurers say they already have medical professionals review all authorization denials.
Starting next year, companies will honor existing prior authorizations for similar care if patients switch insurance companies mid-treatment for up to 90 days. That’s also when insurers will have to start providing easier-to-understand explanations when they deny authorizations and offer guidance about how to appeal.
According to AHIP, at least 80% of electronic requests will be answered in real-time by 2027.
No details were given yet on when insurers may reduce the number of medical services subject to prior authorizations, or which services they would be.
