Health Insurance News – Who Benefits from the New Prior Authorization Changes—and Who Doesn’t?

Health Insurers Promise to Streamline Prior Authorization: Will It Deliver?

UnitedHealthcare, Kaiser Permanente, and dozens of other major U.S. health insurers are pledging to make it faster and easier for patients to get the care they need. But will these changes truly fix the system—or just scratch the surface?

The Problem: Delays That Frustrate Patients and Doctors

Prior authorization, often called “preapproval,” is a process where healthcare providers must get approval from insurers before delivering certain treatments or procedures. While insurers argue it ensures care is safe and cost-effective, critics say it’s a bureaucratic nightmare.

According to the American Medical Association, doctors’ offices spend an average of 12 hours per week navigating prior authorization requests. That’s time taken away from patient care. For patients, these delays can mean waiting weeks—or even months—for essential treatments.

“The health care system remains fragmented and burdened by outdated manual processes,” said AHIP CEO Mike Tuffin. “Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care.”

The Plan: What Insurers Are Promising

Under the new initiative, insurers have committed to several changes aimed at speeding up the process. Here’s what they’re pledging:

1. Standardized Online Submissions
   Insurers will create a unified system for submitting prior authorization requests electronically. This will reduce confusion and make the process more efficient for doctors and patients alike.

2. Fewer Claims Requiring Approval
   Many insurers plan to reduce the number of procedures and treatments that require prior authorization. For example, routine surgeries or diagnostic tests may no longer need preapproval.

3. Real-Time Responses
   By 2027, at least 80% of electronic prior authorization requests will be processed in real time. This means patients could get approvals in minutes instead of days.

4. Continuity of Care
   Starting in 2026, when patients switch insurance plans mid-treatment, their new insurer will honor existing prior authorizations for 90 days. This ensures patients don’t face interruptions in care.

5. Transparency and Communication
   Insurers will provide clearer explanations for denials and make it easier for patients to appeal decisions. They’ll also publish data on approval rates and average wait times.

These changes are expected to benefit more than 250 million Americans, according to AHIP, the trade association representing the health insurance industry.

Who’s Affected by These Changes?

These reforms won’t just impact individual plans. They’re set to shake up a wide range of insurance types. Here’s the breakdown:

• Commercial Plans: This includes individual plans from the ACA marketplace and some employer-sponsored plans.
• Medicare Advantage: Private plans offering Medicare benefits are part of the initiative.
• Medicaid Managed Care: Medicaid plans run by private insurers will also see changes.
• State Blue Cross and Blue Shield Plans: Many state-level Blue Cross and Blue Shield insurers have signed on.

But there are gaps. Large employer-sponsored plans—which cover millions—aren’t fully included. These plans are regulated under ERISA, so they’re not bound by these voluntary changes. And here’s another big miss: prescription drugs. The reforms don’t touch prior authorization for medications, a major pain point for patients.

In total, the changes could benefit 250 million Americans. But how much you’ll feel the impact depends on your plan.

The Critics: Is This Enough?

While the promises sound great, not everyone is convinced. Critics argue that these voluntary changes might not go far enough to address the root problems of prior authorization. Here’s what they’re saying:

• Voluntary Isn’t Binding
  Without government enforcement, there’s no guarantee insurers will follow through. “What happens if they don’t meet their 2027 goals? There’s no penalty,” one healthcare advocate pointed out.

• Gaps in Coverage
  The new rules don’t apply to prescription drugs, which are a major source of frustration for patients. Step therapy requirements, where patients must try cheaper alternatives before getting the medication their doctor recommends, remain untouched.

• Employer-Sponsored Plans Left Out
  Most Americans are covered by employer-sponsored health plans, which aren’t subject to these changes. That leaves millions of people without relief.

• Transparency Isn’t Enough
  Publishing data on approval rates and wait times is a step forward, but critics argue it doesn’t address the underlying issue: why so many procedures require prior authorization in the first place.

• Appeals Process Still Complicated
  While insurers promise clearer communication, the appeals process remains daunting for many patients. A recent study found that only a small percentage of denied claims are ever appealed, even though most appeals are successful.

Shawn Martin, CEO of the American Academy of Family Physicians, called the initiative a “step in the right direction” but emphasized that the real test will be its impact on patients and doctors. “We’ll ultimately measure its success by real changes in the day-to-day experiences of patients and the physicians who care for them,” he said.

The Bigger Picture: A Step Toward Healthcare Reform?

This initiative aligns with broader efforts to modernize healthcare. By reducing red tape, insurers hope to improve access to care and cut costs. But it’s just one piece of the puzzle. Issues like prescription drug coverage, mental health parity, and appeals processes still need attention.

Some experts believe government regulation is necessary to ensure lasting change. The Centers for Medicare and Medicaid Services (CMS) has already issued new rules for Medicare Advantage and Medicaid plans, requiring faster decisions and more transparency. But these rules don’t apply to most employer-sponsored health plans, leaving a significant gap.

Even with these changes, critics argue that prior authorization will remain a tool for insurers to control costs—sometimes at the expense of patient care. “This is a step forward, but it’s not a cure-all,” said one policy expert. “We need systemic reform to truly fix the system.”

List of Companies that are implementing these changes:

• AmeriHealth Caritas
• Arkansas Blue Cross and Blue Shield
• Blue Cross of Idaho
• Blue Cross Blue Shield of Alabama
• Blue Cross Blue Shield of Arizona
• Blue Cross and Blue Shield of Hawaii
• Blue Cross and Blue Shield of Kansas
• Blue Cross and Blue Shield of Kansas City
• Blue Cross and Blue Shield of Louisiana
• Blue Cross Blue Shield of Massachusetts
• Blue Cross Blue Shield of Michigan
• Blue Cross and Blue Shield of Minnesota
• Blue Cross and Blue Shield of Nebraska
• Blue Cross and Blue Shield of North Carolina
• Blue Cross Blue Shield of North Dakota
• Blue Cross & Blue Shield of Rhode Island
• Blue Cross Blue Shield of South Carolina
• BlueCross BlueShield of Tennessee
• Blue Cross Blue Shield of Wyoming
• Blue Shield of California
• Capital Blue Cross
• Capital District Physicians’ Health Plan, Inc. (CDPHP)
• CareFirst BlueCross BlueShield
• Centene
• The Cigna Group
• CVS Health Aetna
• Elevance Health
• Excellus Blue Cross Blue Shield
• Geisinger Health Plan
• GuideWell Mutual Holding Corporation
• Health Care Service Corporation
• Healthfirst (New York)
• Highmark Inc.
• Horizon Blue Cross Blue Shield of New Jersey
• Humana
• Independence Blue Cross
• Independent Health
• Kaiser Permanente
• L.A. Care Health Plan
• Molina Healthcare
• Neighborhood Health Plan of Rhode Island
• Point32Health
• Premera Blue Cross
• Regence BlueShield, Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah, Asuris Northwest Health, BridgeSpan Health
• SCAN Health Plan
• SummaCare
• UnitedHealthcare
• Wellmark Blue Cross and Blue Shield