Washington – The Secretary of Health and Social Services, Robert F. Kennedy Jr., said on Monday that the largest health insurers in the country had promised to take measures to rationalize the often criticized previous authorization process, which can delay or refuse patient access to care.
Prior authorization is a cost reduction tool used by health insurers who force them to sign tests, procedures or drugs before patients can obtain them.
Insurance tactics drew renewed attention last year after the Mortelle shooting by Brian Thompson, CEO of Unitedhealth’s Insurance Arm, in New York.
Patients and doctors claim that the prior authorization creates too many roadblocks, forcing people to wait for days or weeks for the necessary treatments or to refuse them completely.
According to a KFF survey, a research group on health policies.
Kennedy said that a certain number of large insurance companies – including Blue Cross Blue Shield Association, Cigna, Elevance Health, Guidewell, Humana, Kaiser Permanent and Unitedhealthcare – have committed to making changes, which will be implemented throughout private insurance, Medicare Advantage and Medicaid.
AHIP, a commercial group of the health insurance industry, said that changes may benefit 257 million people in the United States.
Experts, however, stressed that the prior authorization does not disappear.
He “will rationalize him in an incremental way,” said Dr. Adam Gaffney, intensive care doctor and assistant professor at the Harvard Medical School.
Health insurance companies have made similar commitments to set prior authorization in the past, a Kennedy fact and Dr. Mehmet Oz, administrator of Centers for Medicare & Medicaid Services (CMS), recognized on Monday during a media event. In 2018 and again in 2023, health insurance companies undertook to reform prior authorization, said OZ, but many have failed to implement such reforms.
Asked what is different this time, he said: “There is violence in the streets on these problems”, alluding to the Thompson shooting.
AHIP – Formerly American health insurance plans – detailed the stages that health insurance companies were engaged in a press release earlier on Monday.
From next year, if patients change insurance plans during their treatment, their new plans will honor existing previous authorizations for similar care for 90 days. In addition, next year, insurers will have to provide explanations that are easier to understand when they refuse authorizations and offer advice on how to call.
Insurers have undertaken to ensure that health professionals examine all the refusals of authorization, although Auil has said that it is something that insurers already say.
Insurers have also undertaken to rationalize the prior authorization process by facilitating the submission of online requests by 2027. At least 80% of electronic requests will be responded in real time by 2027, said AHIP.
Plans can also reduce the number of medical services subject to previous authorizations in certain cities or states – although specific commitments on what could include was lacking.
Chris Klomp, who heads the CMS Medicare program, said the agency would like insurers to strengthen the previous authorization requirements for common services, including colonoscopies, cataract surgery and childbirth.
Kennedy also said that CMS is working with insurers to facilitate prior authorization from diagnostic imaging, physiotherapy and ambulatory surgery.
Gaffney criticized the promises, saying that insurers had decades to change their practices.
“The conversation is cheap,” said Gaffney. “A more fundamental reform will be necessary to approach the omnipresent obstacles to care imposed by insurance firms.”
Kaye Pestaina, director of the Protection of Patients and Consumers in KFF, said that certain commitments may have direct impacts on patients, such as the honor of previous authorizations existing for three months after patients have changed insurers.
