Prior authorization has lengthy been a sticking level between payers and suppliers, with payers arguing that it’s mandatory to manage prices and be sure 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 — similar to UnitedHealthcare, Aetna, Cigna and a number of other Blues plans — made a sequence of commitments in partnership with the Facilities for Medicare and Medicaid Companies to simplify prior authorization, together with offering extra clear explanations of prior authorization determinations, rising turnaround instances for determinations and guaranteeing continuity of care when sufferers swap 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 enhancing the prior authorization course of. … With many enhancements going stay in January, we stay dedicated to streamlining processes and lowering the scope of necessities to enhance the expertise for sufferers and suppliers,” a Blue Cross Blue Defend Affiliation consultant who declined to be named advised MedCity Information.
Nonetheless, the query stays of whether or not these commitments will likely be sufficient for suppliers, who typically appear cautiously optimistic in regards to the commitments.
“Any step towards lowering prior authorization is welcome, and household physicians have been asking for aid for years,” mentioned 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; practically 90% of physicians say it’s extraordinarily burdensome. Till we see significant adjustments that truly cut 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 Mannequin, which extends prior authorization necessities into conventional Medicare. In 2026, consultants may even be watching out for developments within the Enhancing Seniors’ Well timed Entry to Care Act, which might streamline prior authorization in Medicare Benefit.
What are the commitments in 2026?
In response to 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 cut back prior authorization necessities for sure claims, which is able to rely in the marketplace every plan serves. These reductions are anticipated to start out January 1, 2026.
- Guaranteeing continuity of care when sufferers swap plans: When sufferers swap insurance policy throughout remedy, their new insurer should honor current prior authorizations for comparable in-network providers for 90 days to make sure continuity of care and stop delays. This can start January 1, 2026.
- Enhancing communication and transparency on determinations: The insurers pledge to offer clear explanations of prior authorization determinations, in addition to data on appeals. This will likely be accessible for absolutely insured and business protection by January 1, 2026.
In 2027, payers will concentrate on standardizing digital prior authorization and increasing real-time responses. Insurers anticipate that at the least 80% of digital prior authorization approvals will likely be answered in real-time.
In complete, 53 plans signed all of those commitments, together with the largest names on the planet of healthcare insurance coverage: UnitedHealthcare, Elevance Well being, Aetna, Cigna, Kaiser Permanente, Centene, Humana, Highmark and a number of other Blues plans.
AHIP Spokesperson Chris Bond advised MedCity Information that progress will likely be tracked and reported publicly. The group anticipates that the primary report will come within the spring of 2026.
A number of payers advised MedCity Information that they’re on monitor for the commitments in 2026. Dr. Muhannad Hammash, company vice chairman of medical coverage at SCAN Well being Plan, mentioned the nonprofit Medicare Benefit insurer has been working carefully with its supplier companions to make sure readiness, together with internet hosting an October summit to evaluation the commitments and holding one-on-one conferences with particular person teams to assist them perceive and put together for the adjustments.
That mentioned, 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 expertise infrastructure and sources wanted to submit prior authorization requests electronically.
“A few of these applied sciences are costly, particularly for smaller teams,” Hammash mentioned. “That’s one of many challenges we’ve to look into and see what’s the easiest way we are able to work with these suppliers in resolving these points, as a result of we’ve to maneuver from the standard means of paperwork and faxes to utilizing expertise that will assist us pace up the method.”
An government at Blue Defend of California echoed the necessity for extra superior expertise 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 computerized approvals at scale,” mentioned Dr. Laurine Tibaldi, vice chairman of medical administration at Blue Defend of California. “We are going to hopefully see extra suppliers improve their use of expertise to speak with well being plans wherever attainable – instead of faxes or telephone calls. Extra real-time communications between well being plans and suppliers will assist sufferers get care quicker and cut back stress for everybody concerned.”
Aetna President Steve Nelson advised MedCity Information that the insurer is working to meet these commitments and shoot even greater. For instance, it introduced 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 mentioned 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 accredited? 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 a little bit skepticism as effectively.
To carry payers accountable, Brull mentioned suppliers ought to be certain that to doc delays, denials and inconsistencies and convey these issues to lawmakers.
A Medicare coverage professional 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 guaranteeing that plans comply with by way of. She added that CMS Administrator Dr. Mehmet Oz has mentioned that the company is ready to behave if plans don’t comply with by way of.
“Actually, CMS may go additional in proscribing plans’ use of prior authorization,” she mentioned 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 can even take their very own steps to enhance prior authorization, Nonnemaker’s colleague famous.
“It takes two to tango,” mentioned Jeffrey Davis, a director at McDermott+. “So if the payers need to automate the method, meaning the supplier aspect should have the expertise 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,” mentioned Sanjay Doddamani, founder and CEO of GuideHealth, in an electronic mail. “Treating prior auth as a shared scientific and operational workflow, fairly than a downstream administrative process, is vital to lowering friction.”
Past these commitments, Brull is hopeful that there will likely 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 onerous to get it throughout the end line,” she mentioned. “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 to concentrate on caring for sufferers, not paperwork.”
It is 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 motive for lowering prior authorization as effectively. In response to a examine revealed 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 mentioned that new innovation fashions may “reintroduce prior authorization below completely different names or mechanisms, which suggests practices have to remain vigilant simply to maintain affected person care shifting.”
For example, in June, CMS Innovation Heart 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 sluggish look after seniors and add extra administrative challenges to practices, she mentioned.
Picture: Piotrekswat, Getty Photographs
