U.S. Insurers Revise Approval Process

Health plans under major U.S. insurers have voluntarily agreed to speed up and reduce prior authorizations, a process that is often a major pain point for patients and providers when getting and administering care. Prior authorization makes providers obtain approval from a patient’s insurance company before they carry out specific services or treatments. Insurers say the process ensures patients receive medically necessary care and allows them to control costs. But patients and providers have slammed prior authorizations for, in some cases, leading to care delays or denials and physician burnout.

Commitments from Major Insurers

Dozens of plans under large insurers such as CVS Health, UnitedHealthcare, Cigna, Humana, Elevance Health, and Blue Cross Blue Shield committed to a series of actions that aim to connect patients to care more quickly and reduce the administrative burden on providers. Insurers will implement the changes across markets, including commercial coverage and certain Medicare and Medicaid plans. The group said the tweaks will benefit 257 million Americans.

Background and Motivation

The move comes months after the U.S. health insurance industry faced a torrent of public backlash following the murder of UnitedHealthcare’s top executive, Brian Thompson. It builds on the work several companies have already done to simplify their prior authorization processes.

Key Reforms

Among the efforts is establishing a common standard for submitting electronic prior authorization requests by the start of 2027. By then, at least 80% of electronic prior authorization approvals with all necessary clinical documents will be answered in real time. That aims to streamline the process and ease the workload of doctors and hospitals, many of whom still submit requests manually on paper rather than electronically. Individual plans will reduce the types of claims subject to prior authorization requests by 2026.

Reaction from the Medical Community

“We look forward to collaborating with payers to ensure these efforts lead to meaningful and lasting improvements in patient care,” said Shawn Martin, CEO of the American Academy of Family Physicians.

Conclusion

The voluntary agreement by major U.S. insurers to reform prior authorization processes is a significant step towards improving patient care and reducing administrative burdens on healthcare providers. By streamlining and simplifying the process, insurers aim to ensure that patients receive timely and necessary care, while also reducing the workload of doctors and hospitals.

FAQs

Q: What is prior authorization, and why is it used?

A: Prior authorization is a process where healthcare providers must obtain approval from a patient’s insurance company before carrying out specific services or treatments. It is used to ensure that patients receive medically necessary care and to control costs.

Q: What changes are being made to prior authorization processes?

A: Insurers are committing to establish a common standard for submitting electronic prior authorization requests, reduce the types of claims subject to prior authorization requests, and answer at least 80% of electronic prior authorization approvals in real time by 2027.

Q: How will these changes benefit patients and providers?

A: The changes aim to connect patients to care more quickly, reduce care delays or denials, and ease the administrative burden on providers, ultimately leading to meaningful and lasting improvements in patient care.

Q: How many Americans will be affected by these changes?

A: The tweaks are expected to benefit 257 million Americans across various markets, including commercial coverage and certain Medicare and Medicaid plans.