Health insurers tell HHS, CMS they’ll fix prior authorization system

U.S. Health and Human Services Secretary Robert F. Kennedy, Jr. and Centers for Medicare & Medicaid Services Administrator Dr. Mehmet Oz  met with industry leaders to discuss their pledge to streamline and improve the prior authorization processes for Medicare Advantage, Medicaid, Affordable Care Act marketplace and commercial plans covering nearly eight out of 10 Americans.

Companies and organizations represented at an HHS roundtable included Aetna, AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Kaiser Permanente, and UnitedHealthcare.

Earlier, AHIP announced health insurers pledged to focus on connecting patients more quickly to the care they need while minimizing administrative burdens on providers.

For patients, these commitments will result in faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system.

For providers, these commitments will streamline prior authorization workflows, allowing for a more efficient and transparent process overall, while ensuring evidence-based care for their patients.

“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. 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,” said AHIP president and CEO Mike Tuffin.

Participating health plans commit to:

• Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions for electronic prior authorization. This commitment includes the development of standardized data and submission requirements (using FHIR® APIs) that will support seamless, streamlined processes and faster turn-around 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.
• 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.

• Enhancing Communication and Transparency on Determinations. Health plans 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 and commercial coverage by January 1, 2026, with a focus on supporting regulatory 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. 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 – a standard already in place. This commitment is in effect now.

The following health plans voluntarily committed to these actions:

• 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.
• 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 Jersey
• 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

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected].