Insurers' New Prior Authorization Pledge Draws Skepticism

Medscape

6 hours ago

As US health insurers promote a new joint plan to overhaul prior authorization (PA) as a major advance, clinician and patient advocates say insurers have provided few specifics about what will change and how they'll be held accountable.
For example, the voluntary plan unveiled on Monday promises that insurers will reduce the PA burden on providers and patients, but no numbers are provided. And insurers only pledged to 'work' toward overhauling the electronic PA system with a goal of implementation by 2027.
'There are some incremental things that go above and beyond what they're required to do, but there are few concrete commitments,' California-based consultant and former healthcare executive Seth Glickman, MD, MBA, told Medscape Medical News . 'There's not a lot here to ensure their actions are going to match their words.'
Glickman also highlighted what he called a 'one-sided' accompanying report by the America's Health Insurance Plans (AHIP) trade association that defends PA as a 'critical safeguard in patient care,' says it 'is only selectively used,' and blames 'a number of physicians' who don't follow evidence-based medicine.
The growing use of PA to reflexively deny healthcare has sparked outrage from clinicians and patients, leading to action from state and federal lawmakers.
The American Society of Clinical Oncology has tracked more than 110 PA bills in 40 states. The 2024 assassination of UnitedHealthCare CEO Brian Thompson spotlighted the burdens insurers have placed on patients and providers.
'There's violence in the streets over these issues," said Mehmet Oz, MD, MBA, administrator of the Centers for Medicare and Medicaid Services (CMS), at a press conference announcing the new PA reform plan. 'This is not something that is a passively accepted reality anymore — Americans are upset about it.'
Here's a closer look at the PA reform plan and the reaction from the medical community.
A Framework to 'Simplify' PA
AHIP announced on Monday that leading commercial, Medicare Advantage, and Medicaid managed care coverage insurers covering 257 million Americans will voluntarily 'simplify' PA.
'For patients, these commitments will result in faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system,' an AHIP press release said. '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.'
Specifically, insurers agreed to:
Aim to release a framework by January 1, 2027, that will ' work toward implementing common, transparent submissions for electronic prior authorization.' As the AHIP's own report noted, an insurer survey found that 'almost half of prior authorization requests are submitted manually by phone, fax, or mail.'
Reduce PA requirements in fully insured, ACA Marketplace and Medicare Advantage coverage, 'with demonstrated reductions' by January 1, 2026. The plans 'further commit that they will provide data to allow industry reporting of the extent of such reductions reflecting actions taken since January 2024.'
There's no specific goal for reduction of PA requirements.
According to an AHIP survey, 96% of prescription drug claims and 93% of medical claims are not subject to PA. However, a 2025 KFF report found that 'virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services.'
Real-Time Responses and Limiting Use of Artificial Intelligence (AI)
The plans also agreed to:
Honor previous PA authorizations for benefit equivalent in-network services during 90-day transition periods between plans as of January 1, 2026. Medicare Advantage plans are currently required to provide a variation of this.
By January 1, 2026, 'provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps.'
According to the AHIP survey, commercial plans have PA denial rates of 3% for medical services and 10% for prescription medicines.
The KFF report about Medicare Advantage plans found that insurers fully or partially denied 6.4% of PA requests in 2023, and 11.7% of those requests were appealed. While appeals were rare, 81.7% were partially or fully overturned.
'Commit to an acceleration of the percentage of prior authorization requests for medical services answered in real time if submitted electronically by providers with all necessary clinical documentation. By 2027, for all coverage types, at least 80% of prior authorization approvals will be answered in real time.'
According to the AHIP survey, about 20% of current PA requests for medical services are approved in real time; the data for prescription medications were not provided.
'Affirm that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals — a standard already in place.'
The AHIP survey says all responding health plans said, 'AI or algorithms without clinician or practitioner review are not used to deny prior authorization requests that involve medical necessity or clinical considerations.'
Insurers Are Responding to Pressure
Glickman, the consultant, said efforts to 'put a face and a name to the people who are impacted by prior authorization requirements and denials of care' have made a difference.
He added that the Biden Administration helped pave the way for changes at the federal level. 'It would be disingenuous,' he said, for the Trump Administration 'to say they're the ones setting the priorities.'
However, the Trump Administration now has the power to force changes in PA requirements.
'We're throwing money away on administrative costs financially. We're also wasting people's time,' Oz said, according to NBC Chicago. 'The most important reality is the administration has made it clear we're not going to tolerate it anymore. Either you fix it, or we're going to fix it. They wisely decided they should fix it.'
Medical Organizations Respond Cautiously
Medical organizations support the announced reforms — but also called for more than promises.
'Patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions to bring immediate and meaningful changes, break down unnecessary roadblocks, and keep medical decisions between patients and physicians,' said Bobby Mukkamala, MD, president, American Medical Association, in a statement.
Chet Speed, JD, chief policy officer of the American Medical Group Association, told Medscape Medical News that 'the vast majority of PA denials are an inefficient, bureaucratic exercise.'
As he noted, researchers have found that high rates of denials are overturned on appeal. And a 2022 federal analysis of a small group of Medicare Advantage PA denials found that 13% would have been cleared under traditional Medicare.
Speed also highlighted a 2022 American Medical Association survey of 1000 physicians that found 94% of physicians said PA at least sometimes leads to delays in care, and 7% said it 'resulted in a serious adverse event leading to a patient's disability, permanent bodily damage, congenital anomaly, birth defect, or death.'
'Anecdotally, we have heard from medical groups and systems that this delay is especially problematic on Fridays when PA offices close for the weekend,' Speed said, 'meaning patients stay in the hospital when a transfer to a post-acute setting would have been more clinically appropriate.'
As for the new reform plan, Speed said 'the big deal' is that the White House, Department of Health and Human Services, and CMS support it. 'We believe the plan is a good first step,' he said, although he acknowledged that its details about reducing PA burden are 'vague.'
Experts Weigh in With Skepticism — and Hope
Kaye Pestaina, JD, director of the Program on Patient and Consumer Protections at KFF, told KFF Health News that she's not sure how the reform plan changes the fact that many patients don't realize they need PA until it's denied.
'So much of the prior authorization process is behind the black box,' she said.
Adam Gaffney, MD, MPH, a critical care physician and assistant professor at Harvard Medical School, Boston, was skeptical too. He told NBC News that the plan is 'going to streamline it [PA] in some incremental ways only.'
Sabin Dang, MD, a retinal specialist in St. Louis, told Medscape Medical News that the plan won't solve all PA problems.
However, 'one of the things I'm most excited about is real-time answers, using technology to get answers while patient is sitting in the chair and then start the treatment process,' he said. This is much better than forcing patients to wait a week 'while they're suffering with decreased vision,' he added.
Last year, Dang led a study that found 96.2% of PA requests for 2225 anti-VEGF drugs were approved, but most — 59.6% — remained unresolved after 24 hours. Most requests resulted in a delay of care, and an analysis showed that staff members needed to spend a median of 100 minutes on each request.
The standardizing of PA technology will also be helpful, Dang said. 'We have many digital tools and websites to visit,' he said, although he added that fixing the system will be a 'huge logistical hurdle.'
For his part, consultant Glickman said instant approvals raise questions about the true purpose of PA. 'If they're going to be auto-authorized, why are we requiring providers to jump through all these hoops to get authorization in the first place?'