Major health insurers agree to reduce prior authorization burden for imaging and other services
Major health insurers on Monday shared a commitment to reduce the burden of prior authorization for imaging and other services.
AHIP, the industry’s largest lobbying group, made the announcement alongside companies including UnitedHealthcare, Humana, Cigna and the Blue Cross Blue Shield Association. Their action will span commercial, Medicare Advantage and Medicaid managed care plans, impacting some 257 million Americans.
Over 50 payers are voluntarily committing to standardize electronic prior authorization (by 2027), reduce the scope of claims subject to it (2026), and ensure continuity of care when patients change plans (2026). They’ll also look to enhance communication and transparency around determinations (2026), expand real-time responses to these requests (80% by 2027) and ensure rejected healthcare service requests are reviewed by medical professionals (no date given).
“The healthcare system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” AHIP President and CEO Mike Tuffin, MBA, said in a statement June 23. “Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system.”
Payers’ commitment comes after bipartisan senators in May reintroduced the Improving Seniors’ Timely Access to Care Act. Supported by the American College of Radiology among others, the bill would enact some of the same reforms announced Monday, albeit only in Medicare Advantage. Others supporting the bill include the Society of Interventional Radiology, American Society for Radiation Oncology, and American Society of Nuclear Cardiology.
Prior authorization is a utilization-management tactic used by insurers to control healthcare services. AHIP and others on Monday emphasized they still believe it is a “a critical safeguard to ensure their members’ care is safe, effective, evidence-based and affordable.” However, radiology and other specialties have expressed concern that payers are abusing the system to try and cut costs and curb payouts for legitimate healthcare services.
Radiology Business Management Association Co-executive Director Linda Wilgus penned a letter to AHIP and CEO Tuffin on Monday, which she shared with Radiology Business. Wilgus expressed appreciation for the commitment to reform prior authorization. She also said the RBMA stands ready to support payer efforts to improve the PA process, which can be “time-consuming and costly.”
“Healthcare providers must dedicate substantial resources to navigate complex and often opaque procedures, diverting valuable time and attention away from patient care. Moreover, delays caused by these requirements can result in adverse health outcomes, including postponed treatment and increased patient stress,” Wilgus wrote Monday. “Radiology, in particular, is significantly impacted—both operationally and financially. While the responsibility for obtaining prior authorization typically falls on the ordering physician, it is often the radiologist who bears the financial consequences when services are denied due to authorization issues. This is especially problematic in hospital settings, where radiologists may not have the ability to pause or delay an exam if prior authorization has not been secured.”
AHIP said that progress on the initiative will be tracked and reported on its website. It also shared comments of support from other organizations such as the American Academy of Family Physicians and the National Health Council, a nonprofit association of health organizations.
Health and Human Services said Monday that it helped to secure the commitment from AHIP and others. The healthcare agency also hosted a roundtable discussion, with participants including Aetna, the BCBSA, Centene, Cigna, Elevance Health, GuideWell, Highmark Health, Humana, Kaiser Permanente, and UnitedHealthcare.
“Americans shouldn’t have to negotiate with their insurer to get the care they need,” HHS Secretary Robert F. Kennedy Jr said in a statement June 23. “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.”
The HHS announcement also included statements of support from two physicians in Congress—Sen. Roger Marshall, MD, R-Kan., who co-sponsored the Senate bill, and Rep. Greg Murphy, MD, R-N.C., co-chair of the House GOP Doctors Caucus.
Physician groups expressed skepticism about the commitment on Monday. AHIP and BCBSA signed a similar letter alongside the Medical Group Management Association and others in 2018. However, “year after year, we continue to hear from physician practices that it is their No. 1 administrative burden,” the MGMA said Monday.
"While we are encouraged by today's announcement from health plans on prior authorization, much of what insurers intend to do has already been mandated by CMS for their Medicare Advantage and Medicaid managed care plans along with similar adoption dates. It makes sense for them to implement changes across commercial products as well,” Anders Gilberg, senior VP of government affairs for the MGMA, which represents some 15,000 group practices in radiology and other specialties, said in a statement June 23. “Seven years after the consensus statement and several CMS final rules later, health insurers appear to finally be taking steps toward implementation. We look forward to receiving more details about the initiative and working towards reducing the overall volume and burden of prior authorization requirements.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.