Payers Say They'll Reform Prior Auth

On June 23, health insurance plans announced a series of alleged commitments to streamline, simplify, and reduce the burdens imposed by prior authorization. Responding to complaints and extensive surveys by the American Medical Association, these new actions aim to get patients to treatment more quickly while reducing the paperwork and appeals that weigh heavily on providers. Before you believe any of what we outline below, consider the source.

These supposed 'commitments' are being implemented across insurance segments, including Commercial, Medicare Advantage, and Medicaid Managed Care, while maintaining compliance with state and federal regulations, and will reportedly benefit 257 million Americans..”

Participating health plans say they are going to:

• Standardizing Electronic Prior Authorization. Participating health plans will collaborate to implement standardized, transparent submissions for electronic prior authorization. This includes the development of standardized data and submission requirements (using FHIR® APIs) that will support streamlined processes and faster turnaround times. The goal is for the new framework to be operational and available to plans and providers by January 1, 2027.

• Reducing the Scope of Claims Subject to Prior Authorization. Individual plans will commit to specific reductions to medical prior authorization as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026. What that means is uncertain--but anything would be an improvement.

• Ensuring Continuity of Care When Patients Change Plans. Beginning January 1, 2026, when a patient changes insurance companies during a course of treatment, the new plan will honor existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions. Here's my question on this--how about not asking for a new prior auth for each new treatment or regimen?

• Enhancing Communication and Transparency on Determinations. Improvement in this area sure won't take a whole lot. Health plans claim they will provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps. These changes will be operational for fully insured (okay, who is fully insured these days??) and commercial coverage by January 1, 2026, with changes for expansion to additional coverage types.

• Expanding Real-Time Responses. In 2027, at least 80 percent of electronic prior authorization approvals (with all needed clinical documentation) will be answered in real-time or so they say. This commitment includes adoption of FHIR® APIs across all markets to further accelerate real-time responses.

• Ensuring Medical Review of Non-Approved Requests. Participating health plans affirm that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals – they say it's a standard already in place. Sure, Jan.

This is not the first time that AHIP members have committed to prior authorization reform. In 2018, a consensus group comprising all the major medical associations and AHIP agreed on several principles for handling and improving prior authorizations. But years later, there was little progress to show for all the promises made, so believe what you will.

The Medical Group Management Association is likewise taking a wait-and-see approach. "While we are encouraged by.. the announcement from health plans on prior authorization, much of what insurers intend to do has already been mandated by CMS for their Medicare Advantage and Medicaid managed care plans along with similar adoption dates," said Anders Gilberg, senior vice president, government affairs, MGMA. "It makes sense for them to implement changes across commercial products as well. MGMA joined a consensus statement with provider groups and health plans in 2018 that had similar agreed-upon principles for improving prior authorization, yet year-after-year we continue to hear from physician practices that it is their number one administrative burden. Seven years after the consensus statement and several CMS final rules later, health insurers appear to finally be taking steps toward implementation. We look forward to receiving more details about the initiative and working towards reducing the overall volume and burden of prior authorization requirements."

The undersigned health plans voluntarily commit to six actions to improve prior authorization for patients and providers.

• AmeriHealth Caritas
• Arkansas Blue Cross and Blue Shield
• Blue Cross of Idaho
• Blue Cross Blue Shield of Alabama
• Blue Cross Blue Shield of Arizona
• Blue Cross and Blue Shield of Hawaii
• Blue Cross and Blue Shield of Kansas
• Blue Cross and Blue Shield of Kansas City
• Blue Cross and Blue Shield of Louisiana
• Blue Cross Blue Shield of Massachusetts
• Blue Cross Blue Shield of Michigan
• Blue Cross and Blue Shield of Minnesota
• Blue Cross and Blue Shield of Nebraska
• Blue Cross and Blue Shield of North Carolina
• Blue Cross Blue Shield of North Dakota
• Blue Cross & Blue Shield of Rhode Island
• Blue Cross Blue Shield of South Carolina
• BlueCross BlueShield of Tennessee
• Blue Cross Blue Shield of Wyoming
• Blue Shield of California
• Capital Blue Cross
• Capital District Physicians' Health Plan, Inc. (CDPHP)
• CareFirst BlueCross BlueShield
• Centene
• The Cigna Group
• CVS Health Aetna
• Elevance Health
• Excellus Blue Cross Blue Shield
• Geisinger Health Plan
• GuideWell Mutual Holding Corporation
• Health Care Service Corporation
• Healthfirst (New York)
• Highmark Inc.
• Horizon Blue Cross Blue Shield of New Jerse
• Humana
• Independence Blue Cross
• Independent Health
• Kaiser Permanente
• L.A. Care Health Plan
• Molina Healthcare
• Neighborhood Health Plan of Rhode Island
• Point32Health
• Premera Blue Cross
• Regence BlueShield, Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, Asuris Northwest Health, BridgeSpan Health
• SCAN Health Plan
• SummaCare
• UnitedHealthcare
• Wellmark Blue Cross and Blue Shield

We have named names here so you can see whether ANY of this will actually come true. We'll see...