Health and Human Services Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services Administrator Dr. Mehmet Oz announced Monday that major health insurance companies have agreed to reform the process in which insurers approve treatments doctors recommend for patients.
Under what is known as prior authorization, doctors or hospitals must get the blessing of an insurance company to move forward on treatments or surgeries, according to USA Today.
Doctors have complained that the process delays or denies necessary treatments, while insurance companies say it stops tests or care that wastes money.
An overhaul will take place for Americans covered by Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace®, and commercial plans covering almost eight out of 10 Americans, according to a news release posted by the Department of Health and Human Services.
Aetna, Inc., AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Inc., Kaiser Permanente, and UnitedHealthcare were represented at a round table that resulted in the agreement to streamline the prior authorization process.
“Thank you to the insurance companies for making these commitments today. Americans shouldn’t have to negotiate with their insurer to get the care they need,” Kennedy said.
“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,” he said.
Oz said the agreement from the insurers is “a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care.
“We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first,” he said.
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The release said insurers have agreed to standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources-based application programming interfaces; reduce which services are subject to prior authorization by Jan. 1, 2026, reduce the response times to requests for prior authorization by 2027, honor existing authorizations during insurance transitions, increase transparency in the priori authorization process, and have all denials reviwed by a medical professional.
Oz said the insurers are making changes voluntarily.
“The pledge is not a mandate. It’s not a bill, a rule. This is not legislated. This is an opportunity for industry to show itself,” Oz said Monday, according to Fox News.
“But by the fact that three-quarters of the patients in the country are already covered by participants in this pledge, it’s a good start, and the response has been overwhelming,” he said.
Oz said doctors are irked that, on average, they spend about 12 hours a week dealing with the cumbersome prior authorization process.
“It frustrates doctors. It sometimes results in care that is significantly delayed. It erodes public trust in the health care system. It’s something we can’t tolerate,” he said.
In the HHS release, Republican Rep. Greg Murphy of North Carolina, who is a doctor, said the change is a step forward.
“As a physician for over 30 years, I witnessed the ridiculous and ever-increasing obstructions caused by insurance companies to delay or deny care to patients. These bureaucratic hurdles end up hurting patients and those who care for them,” he said.
“Practices have had to hire many more staff just simply to fight with insurance companies. I have made reform a top priority of mine since coming to Congress. I am grateful for the collaborative effort by stakeholders to make commitments to streamline approvals and look forward to them delivering on this pledge,” he said.
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