The Trump administration and insurers appear to have their own changes to reimbursement practices in store, with announcements expected next week — adding to funding changes outlined in Congress’ budget reconciliation bills.
The Wall Street Journal reported June 20 that major payers will pledge to make reforms to the prior authorization process. Payers will promise to create a common standard for submitting electronic requests by the start of 2027, people familiar with the matter told the Journal. They will also promise that 80% of electronic requests will be answered in real time, but only if the submission includes needed documentation.
HHS announced that Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz, MD, will “discuss a breakthrough in health insurance that will improve access to care for millions of Americans” on June 23. It is unclear if that announcement is related to the payers’ pledge. A June 20 HHS news release did not provide further details of what will be discussed at the news conference. An HHS spokesperson also declined to comment on whether the pledge and news conference are related. CMS on June 20 also announced a final rule that will shorten the open enrollment period on the ACA exchange and create stricter eligibility verifications for enrollees.
Prior authorization reform has been a top-of-mind issue for health systems and physicians for years. A recent survey conducted by the American Medical Association found that nearly 90% of physicians reported that the process somewhat or significantly increases burnout. Physicians and their staff spend 13 hours each week on prior authorizations and 40% have staff who work exclusively on the process.
In recent years, major payers like UnitedHealthcare and Cigna have cut more than 20% of the procedures requiring prior authorization. The AMA said, however, that “most physicians are not seeing a difference.”
“Of those surveyed, only 16% working with UnitedHealthCare — and the same share of those working with Cigna — reported that these announced changes have actually reduced the volume of prior authorization requirements for their health plans,” the AMA said in an April 24 report.
In January 2024, CMS finalized a rule to streamline the prior authorization process. Beginning primarily in 2026, certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.
The Journal reported that the payers’ pledge also includes a goal of reducing the number of procedures subject to prior authorization, but does not hold companies to specific targets. They also promise that all authorization denials will be reviewed by medical professionals, though the agreement is reportedly likely to leave room for the use of AI tools in the review process.
