Insurers pledge to improve prior authorization – again

By Jarrod Fowler, MHA, FMA Director of Health Care Policy and Innovation

On Monday, the Blue Cross Blue Shield Association, AHIP (a trade organization representing insurers), and 48 carriers announced a plan to ease the burden associated with prior authorization.

Over the next two years, insurers have vowed to reduce the total number of prior authorization requests, improve standardization and response times, and better coordinate with providers concerning the prior authorization process.

If this sounds familiar, it’s because in 2018 payers agreed to rein in prior authorization by signing onto a historic consensus statement alongside the AMA, the American Hospital Association, the Medical Group Management Association, and trade groups representing pharmacists. At that time, insurers made numerous but often vague commitments that should have, in theory, amounted to far less burdensome requirements.

However, survey data from the AMA has consistently shown that physicians continue to see prior authorization as a tremendous barrier to care, often with serious consequences for patients. By 2022, the AMA admitted, “Insurance companies are not following through with agreed upon prior authorization reform,” as evidenced by continued, dismal survey data from physicians. Current survey results show that physicians experience extraordinary problems due to prior authorization, with no clear improvement in sight.

Will this time be different? U.S. Secretary of Health and Human Services Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz, MD, seem optimistic. According to a recent Modern Healthcare article, Dr. Oz said, “There’s violence in the streets over these issues” and “Americans are upset about it.” Dr. Oz believes this time will be different because of the increased number of insurers participating, the negative public sentiment insurers are facing due to prior authorization, and their commitment to interoperability.

The FMA will work to ensure that this “commitment” is not used as a shield to prevent carriers from being subject to reasonable legislation and regulations, such as time limits for responding to prior authorization requests and prohibitions on retroactive denials. Perhaps it is cynical to argue that insurers would oppose additional regulations because they’re “already working on it.” However, it wouldn’t be the first time that more skeptical voices have been proven right in doubting that insurers will voluntarily and sufficiently self-regulate to make it unnecessary to protect patients through legislation.