Payers have made a bold commitment to pre-authentication in 2025. Here’s what to expect in 2026

Prior authorization has long been a sticking point between payers and providers, with payers arguing the need to control costs and ensure that care is medically necessary and providers arguing that it creates administrative burden and delays care.

Regardless of who is right in this debate, it is clear that this practice is in desperate need of improvement. That’s why in June, more than 50 health plans – such as UnitedHealthcare, Aetna, Cigna and several Blues plans – made a series of commitments in partnership with the Centers for Medicare and Medicaid Services to simplify prior authorization, including providing clearer explanations of prior authorization determinations, increasing turnaround times for determinations and ensuring continuity of care when patients change plans. Several of these commitments will come into force in 2026, while others will take effect in 2027.

“We are making significant progress in improving the prior authorization process. … With many enhancements going live in January, we remain committed to streamlining processes and reducing the scope of requirements to improve the patient and provider experience,” a Blue Cross Blue Shield Association representative who declined to be named told MedCity News.

It remains to be seen whether these commitments will be sufficient for providers, who generally seem cautiously optimistic about these commitments.

“Any action to reduce prior authorizations is welcome, and family physicians have been calling for relief for years,” said Dr. Jen Brull, chair of the board of directors of the American Academy of Family Physicians. “From where we sit in exam rooms, commitments alone aren’t enough. Prior authorization still takes an enormous amount of time and causes real delays in care; nearly 90% of doctors say it’s extremely burdensome. Until we see meaningful changes that actually reduce paperwork and speed up approvals, patients and doctors will continue to feel the pressure.”

Beyond these commitments, 2025 saw other developments in the prior authorization landscape, including the introduction of the WISeR model, which extends prior authorization requirements to traditional Medicare. In 2026, experts will also monitor developments on the Improving Timely Access to Care for Seniors Act, which would streamline prior authorization in Medicare Advantage.

What are the commitments in 2026?

According to AHIP’s June announcement, the commitments coming into effect in 2026 are:

• Reduce the scope of claims subject to prior authorization: Insurers will reduce pre-authorization requirements for certain claims, which will depend on the market served by each plan. These reductions are expected to begin on January 1, 2026.
• Ensure continuity of care when patients change plans: When patients change insurance plans during treatment, their new insurer must honor existing prior authorizations for similar in-network services for 90 days to ensure continuity of care and avoid delays. This will start on January 1, 2026.
• Improve communication and transparency on determinations: Insurers commit to providing clear explanations of prior authorization determinations, as well as information on appeals. This coverage will be available for fully insured and commercial coverage by January 1, 2026.

In 2027, payers will focus on standardizing electronic prior authorization and expanding real-time responses. Insurers anticipate that at least 80% of electronic prior authorizations will be responded to in real time.

In total, 53 plans have signed all of these commitments, including the biggest names in the world of health insurance: UnitedHealthcare, Elevance Health, Aetna, Cigna, Kaiser Permanente, Centene, Humana, Highmark and several Blues plans.

AHIP spokesperson Chris Bond told MedCity News that progress will be tracked and made public. The organization expects the first report to arrive in spring 2026.

Several payers told MedCity News they are on track to meet their commitments in 2026. Dr. Muhannad Hammash, vice president of medical policy at SCAN Health Plan, said the nonprofit insurer Medicare Advantage has worked closely with its provider partners to ensure they are prepared, including hosting a summit in October to review the commitments and holding one-on-one meetings with individual groups to help them understand and prepare for the changes.

That said, there remain challenges to putting these commitments in order. For example, meeting the 2027 commitment to electronic prior authorization will require a substantial effort to support providers who currently lack the technological infrastructure and resources to submit prior authorization requests electronically.

“Some of these technologies are expensive, especially for small groups,” Hammash said. “That’s one of the challenges that we need to look at and see what is the best way to work with these suppliers to resolve these issues because we need to move from the traditional method of paperwork and faxes to using technology that would help us speed up the process.”

An executive at California-based Blue Shield echoed the need for more advanced technology to ensure these commitments are met.

“Health plans will need to leverage their internal member, policy, benefits and network information to facilitate automatic approvals at scale,” said Dr. Laurine Tibaldi, vice president of medical management at Blue Shield of California. “We hope to see more providers using technology more to communicate with health plans wherever possible – instead of faxes or phone calls. More real-time communications between health plans and providers will help patients get care faster and reduce stress for everyone involved.”

Aetna President Steve Nelson told MedCity News that the insurer is working to meet those commitments and aim even higher. For example, it announced in December that it was consolidating medical procedures and pharmaceutical drugs into a single prior authorization. Previously, providers had to submit two separate prior authorizations for medical procedures and related medications. In addition, the insurer strives to bring more transparency to the process.

“One of the frustrations with prior authorization is you don’t know where you are in the process,” Nelson said in an interview. “We’ve added functionality into a digital app so you can now know where you are in the process. Is it pending? Has it been denied? What’s next? Has it been approved? What’s happening?”

Will this be enough for providers?

Although doctors are generally optimistic about these commitments, it goes without saying that there is also some skepticism.

To hold payers accountable, Brull said providers should be sure to document delays, denials and inconsistencies and raise those concerns with lawmakers.

A Medicare policy expert at consulting firm McDermott+ — Lynn Nonnemaker — noted that skepticism among providers is both “appropriate and healthy,” and that skepticism will play a role in ensuring plans come to fruition. She added that CMS Administrator Dr. Mehmet Oz said the agency is prepared to act if the plans do not come to fruition.

“Certainly, CMS could go further in restricting plans’ use of prior authorization,” she said in an interview. “One important thing CMS can do is serve as a convener by helping to bring greater standardization to the systems and processes plans use and how providers interact with them. »

While the onus is on insurers to meet these commitments, providers can also take their own steps to improve prior authorization, Nonnemaker’s colleague noted.

“It takes two to tango,” said Jeffrey Davis, principal at McDermott+. “So if payers want to automate the process, that means the provider will need to have the technology and systems in place to manage these automated transactions. Providers also need to buy in and set up their systems. Payers can do whatever they want on their end, but if providers aren’t participating, there won’t be a seamless prior authorization process.”

An executive at GuideHealth, a value and technology-based care services company, echoed this.

“Providers can improve outcomes by standardizing submissions, using structured clinical data, and aligning with evidence-based pathways in collaboration with payers,” Sanjay Doddamani, founder and CEO of GuideHealth, said in an email. “Treating pre-authentication as a shared clinical and operational workflow, rather than a downstream administrative task, is key to reducing friction. »

Beyond these commitments, Brull hopes there will be progress on the Timely Access to Care for Seniors Act, which would streamline prior authorization in Medicare Advantage.

“The House has already passed it once, and we are working hard to get it across the finish line,” she said. “Ultimately, prior authorization should never prevent a patient from receiving timely care, and doctors should be able to focus on patient care, not paperwork.” »

This is a burden felt by most physicians, as 94 percent indicated in an American Medical Association survey that prior authorization causes significant delays in needed care. There is also an economic reason to reduce prior authorizations. According to a study published in Health Affairs, drug pre-authorization costs $93.3 billion per year, including $6 billion for payers, $24.8 billion for manufacturers, $26.7 billion for doctors and $35.8 billion for patients.

Given the burden of prior authorization, Brull is also concerned about some actions CMS is taking that could have a concerning impact. She said new innovation models could “reintroduce prior authorization under different names or mechanisms, meaning practices must remain vigilant simply to maintain patient care”.

For example, in June, the CMS Innovation Center introduced the Wasteful and Inappropriate Service Reduction Model (WISeR), which introduces a prior authorization process into traditional Medicare with the goal of reducing “fraud, waste, and abuse.” This is concerning to Brull, because traditional health insurance has “long been free of these obstacles.” That could slow down elder care and add more administrative challenges to practices, she said.

Photo: Piotrekswat, Getty Images