AHIP: Health Plans Commit to Reforming Prior Authorization Practice
AHIP, the political advocacy and trade association of health insurance companies, announced in a press release on June 23 that health insurance plans made a series of commitments to streamline, simplify, and reduce prior authorization. “Building on health plans’ existing efforts, these new actions are focused on connecting patients more quickly to the care they need while minimizing administrative burdens on providers,” the news release stated.
“These commitments are being implemented across insurance markets, including for those with Commercial coverage, Medicare Advantage, and Medicaid managed care consistent with state and federal regulations, and will benefit 257 million Americans.”
In January of 2024, the Centers for Medicare & Medicaid Services (CMS) finalized a rule focused on streamlining prior authorization of medical services to improve the electronic exchange of health information and prior authorization processes for medical items and services. This came after growing concerns from healthcare providers, who expressed that prior authorization is often used in a manner that results in critical patient care delays and adds preventable costs to the healthcare system.
Meanwhile, prior authorization reform legislation is currently with Congress for consideration. The Improving Seniors’ Timely Access to Care Act legislation aims to enhance access to care for seniors enrolled in Medicare Advantage (MA) plans. An earlier version of the bill passed in the House; however, it stalled in the Senate.
According to AHIP’s news release, the participating health plans commit to:
- Standardizing electronic prior authorization.
- Reducing the scope of claims subject to prior authorization.
- Ensuring continuity of care when patients change plans.
- Enhancing communication and transparency on determinations.
- Expanding real-time responses.
- Ensuring medical review of non-approved requests.
“The healthcare system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. 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,” said AHIP president and CEO Mike Tuffin, in a statement.
“These measurable commitments – addressing improvements like timeliness, scope, and streamlining – mark a meaningful step forward in our work together to create a better system of health,” said Kim Keck, president and CEO, Blue Cross Blue Shield Association, in a statement.
Soumi Saha, svp, Government Affairs, with Premier Inc. shared that Premier welcomed the announcement. “Premier found that claims adjudication cost healthcare providers nearly $20 billion annually….Real-time approvals, fewer hoops for providers and honoring prior authorizations across plans are all steps in the right direction.” However, Saha added, “voluntary pledges aren’t the same as enforceable protections. Patients and providers deserve more than promises—they deserve accountability.”
“We support the industry's commitments to streamline, simplify, and reduce prior authorization,” Aetna president Steve Nelson said in a statement.
A full list of participating health plans and additional information are available at: www.ahip.org/supportingpatients and https://www.bcbs.com/ImprovingPA.
