The nation’s major health insurers are promising to scale back and improve a widely despised practice that leads to care delays and complications.
UnitedHealthcare, CVS Health's Aetna and dozens of other insurers say they plan to reduce the scope of health care claims subject to prior authorization, standardize parts of the process and expand responses done in real time.
Prior authorization means insurers require approval before they’ll cover medical care, a prescription or a service like an imaging exam. Insurers say they do this to guard against care overuse and to make sure patients get the right treatment.
But doctors say the practice has grown in scope and complication, leading to frequent care delays. The fatal shooting of UnitedHealthcare CEO Brian Thompson in December prompted many people to vent their frustrations with coverage issues like prior authorization.
Major health insurers have promised to overhaul the paperwork-laden process before, but little has changed.
Dr. Mehmet Oz, who now oversees the Centers for Medicare and Medicaid Services, said on Monday that insurers are motivated to make something stick this time around.
“There's violence in the streets over this,” Oz said during a news conference Monday, hours after meeting with most major U.S. insurers. “Americans are upset about it.”
Insurers said Monday that they will standardize electronic prior authorization by the end of next year to help speed up the process. They will reduce the scope of claims subject to medical prior authorization, and they will honor the preapprovals of a previous insurer for a window of time after someone switches plans.
They also plan to expand the number of real-time responses, and they say they will ensure that claims denied for clinical reasons will continue to get reviews by “medical professionals.” But they made no promises that those reviewers will be in the same specialty as the treating doctor, a common complaint from physicians.
Insurers have promised to voluntarily make the changes, but Oz said that the Trump administration will look into regulations if progress isn't made.
"You fix it or we’re going to fix it," Oz said.
Researchers say prior authorization has grown more common as care costs have climbed, especially for prescription drugs, lab testing, physical therapy and imaging exams.
“We’re sort of trapped between care being unaffordable and then these nonfinancial barriers and administrative burdens growing worse,” said Michael Anne Kyle, an assistant professor at the University of Pennsylvania who studies how patients access care.
Nearly all customers of Medicare Advantage plans, the privately run version of the federal government's Medicare program, need prior authorization for some services, particularly expensive care like hospital stays, the health policy research organization KFF found in a study of 2023 claims. The study also found that insurers denied about 6% of all requests.
Dr. Ashley Sumrall of Charlotte, North Carolina, says she has seen an increase in prior authorizations required for routine exams like MRIs. An oncologist who treats brain tumors, Sumrall said these images are critical for doctors to determine whether a treatment is working and to plan next steps.
Doctors say delays from requests that are eventually approved or coverage rejections can harm patients by giving a disease time to progress untreated. They also can spike anxiety in patients who want to know whether their tumor has stopped growing and if insurance will cover the scan.
“There’s a term that we use called ‘scanxiety,’ and it’s very real,” said Sumrall, a member of the Association for Clinical Oncology’s volunteer leadership.
Different forms and varied prior authorization policies also complicate the process. Sumrall noted that every insurer “has their own way of doing business.”
“For years, the companies have been unwilling to compromise, so I think any step in the direction of standardization is encouraging,” she said.
The insurers say their promises will apply to coverage through work or the individual market as well as Medicare Advantage plans and the state and federally funded Medicaid program.
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Murphy reported from Indianapolis. Seitz reported from Washington, D.C.
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Tom Murphy And Amanda Seitz, The Associated Press
