And pledges, like promises, are meant to be unbroken.
Late last month, top officials at the Department of Health and Human Services (HHS) and representatives of the nation’s largest health insurance programs pledged to fix what has been widely recognized as a broken prior authorization system. And, yes, we do mean broken.
A Sober Assessment
According to the view of a growing number of industry experts, the increasing imposition of prior authorization requirements by health insurance plans is putting a significant strain on medical providers. And there are numbers to back this up.
Back in December, the American Medical Association (AMA) conducted a survey of 1,000 physicians. Among these were 400 primary care physicians and 600 specialists. One of the general findings of this survey, released last month, was that prior authorizations “impose significant costs on the industry through additional unnecessary office visits, immediate care visits and hospitalizations.” Many physicians reported care delays, patients abandoning recommended treatment and serious adverse events associated with prior authorizations.
In addition to these concerns, prior authorizations take a toll on the physician workforce, as demonstrated in the below AMA findings:
- On average, physician practices complete 39 prior authorizations, per physician, per week.
- Physicians and their staff spend 13 hours each week on prior authorizations.
- Forty percent of physicians have staff who exclusively work on prior authorizations.
- Thirty-one percent of physicians said prior authorizations are often or always denied.
- Three in four physicians said the number of prior authorization denials has “increased somewhat or significantly” over the last five years.
- Nearly nine in 10 reported that the prior authorization process somewhat or significantly increases burnout.
- Sixty-one percent of physicians said they are concerned that AI will increase or already has increased prior authorization denial rates.
So, clearly, there is a problem, and it seems to be getting worse. Enter the new guys at HHS.
A Solemn Assurance
Late last month, HHS Secretary Robert F. Kennedy, Jr. and Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services (CMS), met with insurance industry leaders to discuss strategies to streamline and improve the prior authorization process as found in Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace® and commercial plans covering nearly eight out of 10 Americans.
In a roundtable discussion hosted by HHS, health insurers pledged six key reforms aimed at cutting red tape, accelerating care decisions, and enhancing transparency for patients and providers. Companies represented at the roundtable included Aetna, AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Kaiser Permanente and UnitedHealthcare.
The outcome of this discussion was a document, signed by representatives of the above companies, whereby they pledged to carry out the following commitments:
- Standardize electronic prior authorization submissions.
- Reduce the volume of medical services subject to prior authorization by January 1, 2026.
- Honor existing authorizations during insurance transitions to ensure continuity of care.
- Enhance transparency and communication around authorization decisions and appeals.
- Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027.
- Ensure medical professionals review all clinical denials.
In connection with this project, Secretary Kennedy had this to say:
Thank you to the insurance companies for making these commitments today. Americans shouldn’t have to negotiate with their insurer to get the care they need. Pitting patients and their doctors against massive companies was not good for anyone. We are actively working with industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy, and outpatient surgery.
Administrator Oz also applauded these voluntary actions by the private sector, characterizing them as “a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care.” He went on to note that CMS encourages continued innovation and collaboration but reserves the right to pursue additional regulatory actions, if necessary.
A Fly in the Ointment?
A few days later, CMS announced the rollout of a six-year program that seeks to root out fraud, waste and abuse via . . . wait for it . . . the increased use of the prior authorization process. With the Wasteful and Inappropriate Service Reduction (WISeR) program, CMS will implement a technology-based prior authorization program for 17 services delivered to patients with traditional Medicare. The program is “voluntary,” meaning providers will have the choice of (a) submitting prior authorization requests for the selected services, or (b) subjecting their post-service claim to pre-payment medical review. Certain pain management services, such as ESIs, are part of this pilot program.
WISeR will run from Jan. 1, 2026, through Dec, 31, 2031, and the model will begin with providers in Arizona, Washington, New Jersey, Texas and Oklahoma. Again, this only applies to traditional Medicare and thus doesn’t affect Medicare Advantage plans. To learn more about this program and to see the full list of the 17 applicable services, please click on the following link: wiser-wiser-model-rfa.pdf.
So, while HHS is securing a pledge by industry leaders to lessen the prior authorization burden, its agency, i.e., CMS, is actually promoting the increased use of such authorizations—at least for a limited number of procedures. There seems to be some mixed messages here.