Insurers Make Pledge to Reform Prior Authorization

On Monday, June 23, the Department of Health and Human Services (HHS) announced an initiative coordinated with multiple health insurance companies to streamline prior authorization processes for patients covered by Medicare Advantage, Medicaid managed care plans, Health Insurance Marketplace plans and commercial plans.

Hospitals and health systems across the country, including in Connecticut, have advocated for action to address the misuse of prior authorization.  Inappropriate use of prior authorization practices slows and could deny access to needed and appropriate care. These practices add significant cost to the system — requiring hospitals and health systems to jump through unnecessary administrative hoops.  They affect timely patient discharge to the next care setting or to home, meaning patients remain in the hospital when they no longer need to be there.

Under the new initiative, electronic prior authorization requests would become standardized by 2027.  HHS stated that these reforms complement ongoing regulatory efforts by the Centers for Medicare & Medicaid Services to improve prior authorization, including building upon the Interoperability and Prior Authorization final rule.

Participating insurers pledged to expand real-time responses by 2027. HHS said that the insurers would also commit to reducing the volume of medical services subject to prior authorization by 2026, including those for common procedures such as colonoscopies and cataract surgeries.  Additionally, participating insurers would honor existing prior authorizations during coverage transitions.