HHS announces industry pledge to reduce and simplify prior authorization

Key takeaways:

• Six reforms to streamline and reduce prior authorization will benefit 257 million Americans.
• The pledge “will eliminate a lot” of causes behind delayed health care, HHS Secretary Robert F. Kennedy Jr. said.

WASHINGTON — HHS and health insurance plans announced commitments to streamline, simplify and reduce prior authorizations, ultimately lessening administrative burdens and improving access to care.

According to a press release from America’s Health Insurance Plans (AHIP), these commitments will be implemented across several insurance markets, “including for those with Commercial coverage, Medicare Advantage and Medicaid managed care consistent with state and federal regulations,” which will benefit 257 million Americans.

During a press conference, HHS Secretary Robert F. Kennedy Jr. said, “85% of Americans say they have had delays in health care. We’re going to be able to eliminate a lot of those causes [because] of what we’re doing today.”

Six reforms will streamline prior authorization

According to the release, the 12 participating health insurance companies and dozens of health insurance plans have committed to:

• standardize electronic prior authorization through the development of standardized data and submission requirements;
• ensure continuity of care when patients change plans by honoring existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period;
• reduce the scope of claims subject to prior authorization, with demonstrated reductions by Jan. 1, 2026;
• affirm that all nonapproved requests based on clinical reasons will continue to be reviewed by medical professionals, a standard practice in place now;
• expand the percentage of electronic prior authorization approvals answered in real-time to at least 80% by 2027 along with the adoption of application programming interfaces across all insurance markets; and
• enhance communication and transparency by having health plans “provide clear, easy-to-understand explanations of prior authorization determinations.”

The release said that the goal for the initiative’s framework is to be operational and available to plans and providers by Jan. 1, 2027.

Among the health insurance companies included in the industry pledge are Aetna Inc., Blue Cross Blue Shield Association, Kaiser Permanente and UnitedHealthcare, an HHS press release said.

Health care inaccessibility remains a pressing public health issue, with a recent survey indicating that more than one in three Americans could not access quality health care if they needed it today.

The process of prior authorizations similarly continues to pose difficulties for health care providers across a dozen specialties. Experts previously told Healio that some attempts in recent years to improve the process, like CMS finalizing the Interoperability and Prior Authorization Final Rule, were positive for health care professionals but that more needed to be done.

Pledge is not a mandate but an ‘opportunity’

The release said that the commitments will result in more evidence-based care and faster and greater direct access to appropriate treatments for patients, as well as reduced burdens and a “more efficient and transparent process overall” for health care professionals .

CMS Administrator Mehmet Oz, MD, MBA, said during the press conference that the pledge addresses many “timely” issues in the prior authorization process and “will deliver what is needed by the right way.”

Oz previously called prior authorization a “pox on the system” during his U.S. Senate Committee on Finance hearing in March and underlined the need for a mechanism “to confirm that procedures are worthwhile.”

Oz said that the pledge is not mandate but an opportunity “for the industry to show itself.”

However, “we have the ability through the rules process to enforce preauthorization if necessary,” he added.

Editor’s note: This is a developing news story. Please check back soon for more details.

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