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We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: An industry pledge reportedly reduced prior authorizations by 11%, and CMS proposed a rule requiring payers to respond to drug requests in a timely manner. But experts are concerned about fragmented processes. Last year, HHS and dozens of health insurers announced an industry pledge to streamline and reduce prior authorization. According to America\u2019s Health Insurance Plans (AHIP), that pledge has led to an 11% reduction in prior authorizations \u201cacross a range of medical services,\u201d leading to 6.5 million fewer prior authorizations.
AHIP also announced that health insurers participating in the pledge will standardize the process for submitting electronic prior authorization requests for most services, including imaging services like CT scans and MRIs and orthopedic surgeries. These services span Medicare Advantage, commercial coverage and Medicaid managed care, with more to come, according to an AHIP press release. Despite the AHIP report, many health care professionals remain unconvinced about how effective the prior authorization pledge will end up being. A recent AMA survey of 1,000 physicians showed that only 33% believe the industry pledge will make a meaningful difference. \u201cI have honestly not heard from a lot of members that they\u2019ve seen an impact in their practices at this point,\u201d ACP Chief Advocacy Officer and Senior Vice President of Governmental Affairs and Public Policy Shari M. Erickson, MPH, told Healio. \u201cNow, we haven\u2019t conducted a survey recently to ask them about this, so perhaps in aggregate we might find out from some that they are seeing some improvements, but I certainly have not heard it from any of them voluntarily.\u201d Patients still struggling with prior authorization Many patients continue to report disruptions in health care stemming from insurance coverage issues. A 2025 analysis from The Commonwealth Fund showed that 21% of U.S. working-age adults with private health insurance were denied coverage for medical care recommended by a physician in the past year. Among them, 41% said it led to delayed care, 28% said it worsened a health problem and 61% said the denial caused anxiety and worry. Just half of those denied care appealed it, \u201cciting uncertainty over their right to do so and whether it would make a difference if they did, as well as confusion about who to contact,\u201d according to a press release. Further, a recent Annals of Internal Medicine study found that prior authorization rules remain inconsistent among commercial insurers. For example, \u201cfor approval of a prior authorization for medical and surgical services, Aetna only required a site-of-service review, while UnitedHealthcare used this and two other requirements,\u201d Aya Zaari Jabri, MS, a study co-author from Stanford University, and colleagues wrote. \u201cAcross all Healthcare Common Procedure Coding System codes, none of the insurers used the same criteria to require prior authorization or the same requirements to obtain prior authorization.\u201d So, despite the industry pledge\u2019s intent to improve prior authorizations, Jabri and colleagues said the pledge does nothing to eliminate fragmented processes across insurers. New CMS efforts There has been additional movement in the prior authorization space outside the industry pledge. CMS recently proposed a rule that would extend the CMS Interoperability and Prior Authorization Final Rule to include prescription drugs. Certain federally regulated insurance payers would need to respond to urgent prior authorization requests for all drugs within 24 hours, expedited requests within 72 hours and standard requests within 7 days, as well as publicly report prior authorization metrics for drugs. If finalized, impacted payers would need to comply by Oct. 1, 2027. CMS\u2019 proposal to expand prior authorization requirements to include drugs \u201cis something we absolutely asked for when they first came out with it, and so we\u2019re really pleased to see that in the proposed rules,\u201d Erickson said. \u201cACP is still reviewing it, and I\u2019m not sure what feedback we\u2019ll be giving, but we are definitely pleased it\u2019s moving in this direction.\u201d CMS is also testing the use of AI for processing prior authorization claims and determining approvals through the Wasteful and Inappropriate Service Reduction, or WISeR, Model. The pilot program was launched in six states on Jan. 1. But a report released by Sen. Maria Cantwell, D-Wash., showed that patients\u2019 wait times for procedures under WISeR are two to four times longer due to authorization delays. As a result, providers \u201care spending more time appealing claims,\u201d Cantwell wrote in a letter. According to Erickson, patients in the pilot states are going \u201cfrom 1 to 2 days for quick prior authorization turnaround and 3 to 5 days for standard prior authorization to up to 10 to 15 days.\u201dartificial or augmented intelligence certainly could help in this case, a lot of these are complex types of requests,\u201d Erickson said. \u201cWe feel strongly that you need some level of physician oversight if you are using electronic methods to try to conduct prior authorizations or reduce the need for prior authorization,\u201d she said. \u201cThere\u2019s certainly interest in making things more automated and speedier, but at the same time, it needs to be done appropriately from a clinical perspective.\u201d The \u2018good, bad or otherwise\u2019 ACP has previously called on health insurers to \u201cset clear and measurable benchmarks for improvement,\u201d which Erickson said the industry pledge is seemingly \u201ctrying to do.\u201d \u201cWe also asked them to work with physicians and patients as they were trying to do this, and we haven\u2019t really seen much outreach on that front at this point,\u201d she said. \u201cWe did ask them to ensure transparency, reporting and decision-making, but I\u2019m not sure we\u2019ve seen a lot more transparency in their processes at this point\u201d other than the AHIP report. She added that ACP \u201chas<\/p>\n","protected":false},"author":1,"featured_media":2930,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-2929","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/2929","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2929"}],"version-history":[{"count":0,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/2929\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/media\/2930"}],"wp:attachment":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2929"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2929"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2929"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}