The nation’s largest health insurers, including UnitedHealthcare and CVS Health’s Aetna, are pledging to scale back and streamline the often-criticized process of prior authorization — a move aimed at addressing mounting frustration over care delays and complications.
Prior authorization is a process that requires patients to obtain approval from their insurance company before receiving certain medical services, prescriptions, or procedures. While insurers argue that the practice helps prevent unnecessary care and ensures patients receive appropriate treatment, doctors and patients have long argued that it creates significant barriers to timely care.
The fatal shooting of UnitedHealthcare CEO Brian Thompson in December reignited public anger over insurance practices, with many blaming coverage denials and bureaucratic hurdles like prior authorization for worsening patient outcomes.
Health insurers have promised reforms in the past, but little has changed. This time, however, pressure from both the public and federal officials appears to be forcing action.
In response, insurers announced plans to standardize electronic prior authorization by the end of next year, with the goal of expediting approvals and reducing paperwork. They also vowed to reduce the number of medical claims requiring prior authorization and to honor pre-approvals from previous insurers for a period of time after patients switch health plans.
Additionally, insurers say they will increase the number of real-time authorization responses and ensure that claims denied for clinical reasons continue to be reviewed by medical professionals. However, they stopped short of guaranteeing that those reviewers would be specialists in the same field as the patient’s treating doctor — a frequent concern raised by healthcare providers.
While the changes are currently voluntary, Oz made it clear that the Trump administration is prepared to impose regulations if meaningful progress is not made.
Researchers say the prior authorization process has expanded significantly in recent years, driven by rising healthcare costs, especially for prescription drugs, lab testing, imaging exams, and physical therapy.
According to a 2023 study by the health policy organization KFF, nearly all Medicare Advantage customers — the privately run version of Medicare — face prior authorization requirements for some services, particularly for costly hospital stays. The study also found that insurers denied approximately 6% of all prior authorization requests.
It remains to be seen whether the promised changes will bring meaningful relief to patients or whether regulatory action will ultimately be required to address the longstanding frustrations with the system.
