Health Insurers Vow To Simplify And Reduce Pre-Approval Process

The biggest names in health insurance, including Cigna, CVS Health’s Aetna, UnitedHealth Group’s UnitedHealthcare and Humana are among more than 50 health insurers committing to “streamline, simplify and reduce” prior authorization, the process of insurers reviewing hospital admissions and medications.

The sweeping commitments were announced Monday by America’s Health Insurance Plans, also known as AHIP, and the Blue Cross Blue Shield Association. These groups and their health plan members, which provide health benefits to more than 250 million Americans, say they “aim to accelerate decision timelines, increase transparency and expand access to affordable, quality care.”

Doctors complain prior authorization has delayed needed treatment and put patient health in jeopardy while wasting physician and patient time to jump through hoops. Over the past several years, prior authorization increasingly has become a concern for patient access to needed services, according to almost 30% of physicians responding to an American Medical Association survey in 2023.

The issue of prior authorization has been at the forefront of legislative efforts in Washington and state capitals across the country. The voluntary effort announced Monday could blunt some legislative actions that would mandate health insurer changes.

The scrutiny of health insurers became even more intense after an outpouring of public anger at the health insurance industry following the shooting of UnitedHealthcare CEO Brian Thompson on Dec. 4 of last year. Thompson’s death unleashed a barrage of scrutiny on health insurer denials of medical care and certain other business practices from social media trolls and industry critics including some in Congress who say they’d like to see reform.

“For patients, these commitments will result in faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system,” the groups said in a statement. “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 effort is the latest and biggest so far among health insurers. Earlier this year, The Cigna Group announced a new multi-year effort to improve accountability. And UnitedHealthcare said Monday the insurer has “reduced the number of CPT codes that require prior authorization and recently introduced a first-of-its-kind national Gold Card program.”

Health insurers admit their approval processes have been lacking and, in some cases, wasn’t keeping with advancements in technology and healthcare delivery.

“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” said Mike Tuffin, president and chief executive of AHIP, which includes Centene, Cigna, CVS Health’s Aetna and Humana among its health plan membership. “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.”

The insurers are committed to the changes in all health plans that they sell including commercial coverage, Medicare Advantage for seniors and Medicaid health plans that they administer for low-income Americans via contracts with states.

“These measurable commitments – addressing improvements like timeliness, scope and streamlining – mark a meaningful step forward in our work together to create a better system of health,” Blue Cross Blue Shield Association president and chief executive Kim Keck said. “This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience.”

Health insurers participating broke down their commitments in six areas. They are:

• Standardizing Electronic Prior Authorization. “Participating health plans will work toward implementing common, transparent submissions for electronic prior authorization,” the insurers said. “This commitment includes the development of standardized data and submission requirements … that will support seamless, streamlined processes and faster turn-around times.” The goal is to have electronic prior authorization by Jan. 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,” the insurers said.
• Ensuring Continuity of Care When Patients Change Plans. Effective Jan. 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,” the health plans involved say. “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,” the health plans say. Such 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,” the health plans say.
• 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,” the health plans say.
• 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,” the health plans say. “This commitment is in effect now.”

An entire list of health insurers is here.