Prior
authorization
has
long
been
a
sticking
point
between
payers
and
providers,
with
payers
arguing
that
it’s
necessary
to
control
costs
and
ensure
that
care
is
medically
necessary
and
providers
arguing
that
it
creates
administrative
burden
and
delays
care.
Regardless
of
who’s
right
in
this
debate,
it’s
clear
that
the
practice
is
in
desperate
need
of
improvement.
That’s
why
in
June,
more
than
50
health
plans
—
such
as
UnitedHealthcare,
Aetna,
Cigna
and
several
Blues
plans
—
made
a
series
of
commitments
in
partnership
with
the
Centers
for
Medicare
and
Medicaid
Services
to
simplify
prior
authorization,
including
providing
more
clear
explanations
of
prior
authorization
determinations,
increasing
turnaround
times
for
determinations
and
ensuring
continuity
of
care
when
patients
switch
plans.
Several
of
these
commitments
will
go
into
place
in
2026,
while
others
will
take
effect
in
2027.
“We’re
making
meaningful
progress
on
improving
the
prior
authorization
process.
…
With
many
improvements
going
live
in
January,
we
remain
committed
to
streamlining
processes
and
reducing
the
scope
of
requirements
to
improve
the
experience
for
patients
and
providers,”
a
Blue
Cross
Blue
Shield
Association
representative
who
declined
to
be
named
told
MedCity
News.
Still,
the
question
remains
of
whether
these
commitments
will
be
enough
for
providers,
who
generally
seem
cautiously
optimistic
about
the
commitments.
“Any
step
toward
reducing
prior
authorization
is
welcome,
and
family
physicians
have
been
asking
for
relief
for
years,”
said
Dr.
Jen
Brull,
board
chair
of
the
American
Academy
of
Family
Physicians.
“From
where
we
sit
in
exam
rooms,
commitments
alone
aren’t
sufficient.
Prior
authorization
still
eats
up
an
enormous
amount
of
time
and
causes
real
delays
in
care;
nearly
90%
of
physicians
say
it’s
extremely
burdensome.
Until
we
see
meaningful
changes
that
actually
reduce
paperwork
and
speed
up
approvals,
patients
and
physicians
will
continue
to
feel
the
strain.”
Beyond
these
commitments,
2025
has
seen
additional
developments
in
the
prior
authorization
landscape,
including
the
introduction
of
the
WISeR
Model,
which
extends
prior
authorization
requirements
into
traditional
Medicare.
In
2026,
experts
will
also
be
watching
out
for
developments
in
the
Improving
Seniors’
Timely
Access
to
Care
Act,
which
would
streamline
prior
authorization
in
Medicare
Advantage.
What
are
the
commitments
in
2026?
According
to
AHIP’s
announcement
in
June,
the
commitments
going
into
effect
in
2026
are:
-
Reducing
the
scope
of
claims
subject
to
prior
authorization:
The
insurers
will
reduce
prior
authorization
requirements
for
certain
claims,
which
will
depend
on
the
market
each
plan
serves.
These
reductions
are
expected
to
start
January
1,
2026. -
Ensuring
continuity
of
care
when
patients
switch
plans:
When
patients
switch
insurance
plans
during
treatment,
their
new
insurer
must
honor
existing
prior
authorizations
for
similar
in-network
services
for
90
days
to
ensure
continuity
of
care
and
prevent
delays.
This
will
begin
January
1,
2026. -
Improving
communication
and
transparency
on
determinations:
The
insurers
pledge
to
give
clear
explanations
of
prior
authorization
determinations,
as
well
as
information
on
appeals.
This
will
be
available
for
fully
insured
and
commercial
coverage
by
January
1,
2026.
In
2027,
payers
will
focus
on
standardizing
electronic
prior
authorization
and
expanding
real-time
responses.
Insurers
anticipate
that
at
least
80%
of
electronic
prior
authorization
approvals
will
be
answered
in
real-time.
In
total,
53
plans
signed
all
of
these
commitments,
including
the
biggest
names
in
the
world
of
healthcare
insurance:
UnitedHealthcare,
Elevance
Health,
Aetna,
Cigna,
Kaiser
Permanente,
Centene,
Humana,
Highmark
and
several
Blues
plans.
AHIP
Spokesperson
Chris
Bond
told
MedCity
News
that
progress
will
be
tracked
and
reported
publicly.
The
organization
anticipates
that
the
first
report
will
come
in
the
spring
of
2026.
Several
payers
told
MedCity
News
that
they’re
on
track
for
the
commitments
in
2026.
Dr.
Muhannad
Hammash,
corporate
vice
president
of
medical
policy
at
SCAN
Health
Plan,
said
the
nonprofit
Medicare
Advantage
insurer
has
been
working
closely
with
its
provider
partners
to
ensure
readiness,
including
hosting
an
October
summit
to
review
the
commitments
and
holding
one-on-one
meetings
with
individual
groups
to
help
them
understand
and
prepare
for
the
changes.
That
said,
there
are
challenges
to
getting
these
commitments
in
order.
For
example,
meeting
the
2027
commitment
for
electronic
prior
authorization
will
require
a
substantial
effort
to
support
providers
that
currently
lack
the
technology
infrastructure
and
resources
needed
to
submit
prior
authorization
requests
electronically.
“Some
of
these
technologies
are
expensive,
especially
for
smaller
groups,”
Hammash
said.
“That’s
one
of
the
challenges
we
have
to
look
into
and
see
what
is
the
best
way
we
can
work
with
those
providers
in
resolving
these
issues,
because
we
have
to
move
from
the
traditional
way
of
paperwork
and
faxes
to
using
technology
that
would
help
us
speed
up
the
process.”
An
executive
at
Blue
Shield
of
California
echoed
the
need
for
more
advanced
technology
to
ensure
these
commitments
work.
“Health
plans
will
need
to
leverage
their
internal
intelligence
about
members,
policies,
benefits,
and
networks
to
facilitate
automatic
approvals
at
scale,”
said
Dr.
Laurine
Tibaldi,
vice
president
of
medical
management
at
Blue
Shield
of
California.
“We
will
hopefully
see
more
providers
increase
their
use
of
technology
to
communicate
with
health
plans
wherever
possible
–
in
place
of
faxes
or
phone
calls.
More
real-time
communications
between
health
plans
and
providers
will
help
patients
get
care
faster
and
reduce
stress
for
everyone
involved.”
Aetna
President
Steve
Nelson
told
MedCity
News
that
the
insurer
is
working
to
fulfill
these
commitments
and
shoot
even
higher.
For
example,
it
announced
in
December
that
it
is
bundling
medical
procedures
and
pharmaceutical
medications
into
one
prior
authorization.
Previously,
providers
had
to
submit
two
separate
prior
authorizations
for
medical
procedures
and
related
medications.
In
addition,
the
insurer
is
working
on
bringing
more
transparency
into
the
process.
“One
of
the
frustrations
about
prior
authorization
is
you
don’t
know
where
you
are
in
the
process,”
Nelson
said
in
an
interview.
“We’ve
added
capabilities
in
a
digital
app
so
you
can
now
know
where
you
are
in
the
process.
Is
it
pending?
Has
it
been
denied?
What’s
the
next
step?
Has
it
been
approved?
What’s
going
on
with
it?”
Will
this
be
enough
for
providers?
While
physicians
are
generally
optimistic
about
these
commitments,
it
goes
without
saying
that
there’s
a
little
skepticism
as
well.
To
hold
payers
accountable,
Brull
said
providers
should
make
sure
to
document
delays,
denials
and
inconsistencies
and
bring
those
concerns
to
lawmakers.
A
Medicare
policy
expert
at
consulting
firm
McDermott+
—
Lynn
Nonnemaker
—
noted
that
the
skepticism
among
providers
is
both
“appropriate
and
healthy,”
and
this
skepticism
will
play
a
role
in
ensuring
that
plans
follow
through.
She
added
that
CMS
Administrator
Dr.
Mehmet
Oz
has
said
that
the
agency
is
prepared
to
act
if
plans
don’t
follow
through.
“Certainly,
CMS
could
go
further
in
restricting
plans’
use
of
prior
authorization,”
she
said
in
an
interview.
“One
important
thing
that
CMS
can
do
is
serve
as
a
convener
in
helping
bring
about
more
standardization
of
the
systems
and
processes
that
plans
use
and
the
way
that
providers
interact
with
them.”
Although
the
onus
is
on
the
insurers
to
carry
out
these
commitments,
providers
can
also
take
their
own
steps
to
improve
prior
authorization,
Nonnemaker’s
colleague
noted.
“It
takes
two
to
tango,”
said
Jeffrey
Davis,
a
director
at
McDermott+.
“So
if
the
payers
want
to
automate
the
process,
that
means
the
provider
side
will
have
to
have
the
technology
in
place,
the
systems
in
place,
to
handle
those
automated
transactions.
Providers
have
to
buy
into
this
too
and
set
up
their
systems.
Payers
can
do
all
they
want
on
their
side,
but
if
the
providers
don’t
participate,
there’s
not
going
to
be
a
seamless
prior
authorization
process.”
An
executive
at
GuideHealth,
a
tech-enabled
value-based
care
services
company,
echoed
this.
“Providers
can
improve
outcomes
by
standardizing
submissions,
using
structured
clinical
data,
and
aligning
with
evidence-based
pathways
in
collaboration
with
payers,”
said
Sanjay
Doddamani,
founder
and
CEO
of
GuideHealth,
in
an
email.
“Treating
prior
auth
as
a
shared
clinical
and
operational
workflow,
rather
than
a
downstream
administrative
task,
is
key
to
reducing
friction.”
Beyond
these
commitments,
Brull
is
hopeful
that
there
will
be
movement
on
the
Seniors’
Timely
Access
to
Care
Act,
which
would
streamline
prior
authorization
in
Medicare
Advantage.
“The
House
has
already
passed
it
once,
and
we’re
working
hard
to
get
it
across
the
finish
line,”
she
said.
“At
the
end
of
the
day,
prior
authorization
should
never
stand
between
a
patient
and
timely
care,
and
physicians
should
be
able
to
focus
on
caring
for
patients,
not
paperwork.”
This
is
a
burden
felt
by
most
physicians,
as
94%
reported
in
an
American
Medical
Association
survey
that
prior
authorization
causes
major
delays
in
necessary
care.
There’s
an
economic
reason
for
reducing
prior
authorization
as
well.
According
to
a
study
published
in
Health
Affairs,
drug
prior
authorization
costs
$93.3
billion
annually,
including
$6
billion
for
payers,
$24.8
billion
for
manufacturers,
$26.7
billion
for
physicians
and
$35.8
billion
for
patients.
Given
the
burden
of
prior
authorization,
Brull
is
also
concerned
about
some
moves
that
CMS
is
taking
that
can
have
a
worrying
impact.
She
said
that
new
innovation
models
could
“reintroduce
prior
authorization
under
different
names
or
mechanisms,
which
means
practices
have
to
stay
vigilant
just
to
keep
patient
care
moving.”
For
instance,
in
June,
CMS
Innovation
Center
introduced
the
WISeR
model
(Wasteful
and
Inappropriate
Service
Reduction
Model),
that
brings
a
prior
authorization
process
into
traditional
Medicare
in
an
effort
to
reduce
“fraud,
waste
and
abuse.”
This
is
concerning
to
Brull
as
traditional
Medicare
has
“long
been
free
from
those
hurdles.”
This
could
slow
care
for
seniors
and
add
more
administrative
challenges
to
practices,
she
said.
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