Insurers Pledge to Improve Prior Authorization Process for MA

CMS/Medicare

WASHINGTON—Top United States health insurance providers pledged to streamline and improve the prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace and commercial plans covering nearly eight out of 10 Americans, Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz announced on Monday, June 23. 

In a roundtable discussion hosted by the Department of Health and Human Services (HHS), health insurers pledged six key reforms aimed at cutting red tape, accelerating care decisions and enhancing transparency for patients and providers. Companies represented at the roundtable included Aetna Inc., AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, the Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana Inc., Kaiser Permanente and UnitedHealthcare.

“Thank you to the insurance companies for making these commitments today. Americans shouldn’t have to negotiate with their insurer to get the care they need,” said HHS Secretary Robert F. Kennedy Jr. “Pitting patients and their doctors against massive companies was not good for anyone. We are actively working with (the) industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy and outpatient surgery.”

“These commitments represent a step in the right direction toward restoring trust, easing burdens on providers and helping patients receive timely, evidence-based care,” Oz said. “We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first.”

Participating health insurers have pledged to:

  • Standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR)-based application programming interfaces
  • Reduce the volume of medical services subject to prior authorization by January 1, 2026
  • Honor existing authorizations during insurance transitions to ensure continuity of care
  • Enhance transparency and communication around authorization decisions and appeals
  • Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027
  • Ensure medical professionals review all clinical denials

These private sector reforms complement ongoing regulatory efforts by CMS to improve prior authorization interoperability within Medicare Advantage, Medicaid Managed Care and the Health Insurance Marketplace.

CMS said it encourages continued innovation and collaboration but it reserves the right to pursue additional regulatory actions if necessary.

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