Prior Authorization Payer Changes, Hope or Hype?

Under increasing pressure from the Trump administration, as well as regulatory and public scrutiny related to payer prior authorizations (PAs), a coalition of more than 40 health insurers announced plans for PA reform on June 23, 2025.

The America’s Health Insurance Plans (AHIP) trade association and the Blue Cross Blue Shield Association made the announcement for the coalition, which includes UnitedHealthcare, Aetna, Cigna, Elevance, and Humana, among dozens of other payers.¹

The AHIP announcement spoke of 6 commitments to streamline, simplify, and reduce PAs. The participating coalition of insurance plans includes those with coverage for commercial, Medicare Advantage, and Medicaid managed care. The commitments were positioned as benefiting patients by resulting in faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system. For providers, these commitments were positioned as streamlining PA workflows, allowing for a more efficient and transparent process overall, while ensuring evidence-based care.

The 5 commitments being made by the participating health plans include:

• Standardizing electronic prior authorization—Plans will work toward implementing common, transparent submissions or electronic PAs. The goal for the new framework to be operational and available will be by January 1, 2027
• Reducing the scope of claims subject to prior authorization—Individual plans will commit to specific reductions to medical PAs as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026
• Enhancing communication and transparency on determinations—Plans will provide clear, easy-to-understand explanations of PA determinations, including support for appeals and guidance on next steps. The changes will be operational for fully insured and commercial coverage by January 1, 2026, and support regulatory changes for expansion to additional coverage types
• Expanding real-time responses—Plans will answer at least 80% of electronic PA approvals (with all needed clinical documentation) in real time in 2027
• Ensuring medical review of nonapproved requests—Plans affirm that all nonapproved requests based on clinical reasons will continue to be reviewed by medical professionals—a standard already in place. This commitment is in effect now.²

Promises or Action?

As always, the devil will be in the details. In the wake of recent review by legislators and the Centers for Medicare & Medicaid Services (CMS) on payer aggressive use of PAs, and the public backlash against payer utilization management that followed the fatal shooting of UnitedHealthcare’s CEO, it is possible that this announcement regarding commitments to reform the PA process could be a welcome sensitivity to the burden of PAs on patients and their needed medical care. This new series of commitments also could be just another attempt to mollify market concerns without ever really following through, or worse, using these promises to redirect attention away from aggression in other areas of utilization management.

The President of the American Medical Association (AMA), Dr Bobby Mukkamala, wrote a warning about this announcement on the AMA website, that actions will speak louder than promises. He reminded us of similarly publicized payer outlines for major overhauls of PA processes in 2018 and again in 2023, but that little actual change materialized in the past 7 years. Denials of PAs have increased, antiquated technology such as fax machines and lengthy phone calls are still widely used, and more than three-quarters of the physicians participating in the most recent AMA survey on PAs reported patient abandonment of treatment due to PAs; nearly one-fifth reported that a patient required hospitalization as a result of PA processes. Dr Mukkamala expressed cautious optimism, and the need for careful observation related to the implementation and execution of these 6 payer commitments.³

Voluntary, Not Mandated

Physicians and patients cannot look to these payer pledges as absolute. While federal regulators point proudly to this as a positive reaction to CMS efforts to spearhead the charge to reform PAs, these 6 commitments are not guaranteed. CMS Administrator Dr Mehmet Oz announced on June 23, 2025, that the government will be tracking compliance closely and consider regulation if insurers fail to meet the new standards. For now, Dr Oz states “the pledge is not a mandate. It’s not a bill or rule. This is not legislated. This is an opportunity for industry to show itself.”¹

The commitments themselves reference fully insured commercial markets, but not self-insured employer markets. This will aggravate the growing access-to-care gap for employees of self-insured employer plans that exist exempt from state regulations or insurance protections, and also from voluntary payer commitments such as these.

What Isn’t Being Covered in These Commitments?

We all know the adage, when a door closes, a window opens. A skeptic might look at these commitments and suspect that they are being made now because both public and regulatory outcry against payer utilization management and PAs has grown to an unavoidable crescendo. However, that skeptic may also suspect that the commitments about PAs are a deflection to mask heightened utilization management in other arenas such as step edits, claims denials, and preferred formulary restrictions. Have the participating payers already calculated a more positive impact on their costs from other, less visible, activities, so that they can more easily “give in” to PA reform?

I have mentioned in prior Oncology Practice Management editorials how payers are increasing the use of algorithms to manage claims denials and coverage limitations that occur after the service has already been provided. It is probably easier and cheaper for payers to deny claims or coverage after the service has been provided, since patients may be less likely to appeal the denial. There is no mention in any of these commitments related to actual coverage, approval rates, or standard-of-care coverage guarantees. Federal and ProPublica inquiries and reports about algorithm use in prominent national payers also discovered careful planned scripting of payer staff in speaking with physicians and their staff so as to ensure successful upholding of denials upon appeal—there are no safeguards against such behaviors in the 6 payer PA commitments noted above.⁴

It is distressing to see how much that impacts patient access to care, delays in care, restrictions for care and costs of care (all dictated by payer insurance plans and contracts with providers) are untouched by these 6 heavily touted commitments. None of these commitments address coverage criteria, quality of care in the eyes of physicians and patients, patient out-of-pocket costs, or elimination of PAs, or promise that the streamlining will lead to fewer denials or more approvals (just that the answer will be faster).⁵

What Can Practices Do?

Physicians and patients already battle challenges in accessing appropriate medical care every day. That is not going to change because more than 40 payers issued a press release about voluntary, unmonitored, promises regarding PAs.

The battle for medical care will continue. Such promises have already been made, in a similarly public manner in 2018 and 2023, with no significant or notable improvement for patient access to care. Unfortunately, no cancer center will be able to trust these commitments. All we can do is continue to advocate for our patients, and to track the possible successes, but more likely failures, of the PA process by payers, so that the failures can hopefully lead to accountability, and eventually, unassailable regulatory requirements.

We also need to keep a watchful eye on other changes that may arise that create more obstacles for patients and their access to care: claims denials after care has been delivered, increased step edits, more restrictive drug formularies, and increased use of risky drug importation, or mandated white bagging or brown bagging. Unfortunately, I personally do not see much hope coming out of these PA “commitments,” and fear that these are primarily hype.

Share your thoughts and experiences with me at This email address is being protected from spambots. You need JavaScript enabled to view it.. I would be interested in hearing what you have found, or what more you want to know. I can provide additional resources on this topic if you wish.

References

1. Pifer R. Health insurers, nudged by Trump administration, pledge reform to prior authorization. Healthcare Dive. June 23, 2025. Accessed July 18, 2025. www.healthcaredive.com/news/health-insurers-pledge-prior-authorization-reform-trump-hhs/751309/
2. AHIP. Health plans take action to simplify prior authorization [press release]. America’s Health Insurance Plans. June 23, 2025. Accessed July 18, 2025. www.ahip.org/news/press-releases/health-plans-take-action-to-simplify-prior-authorization
3. Mukkamala B. Action must follow pledges on prior authorization reform. American Medical Association. July 7, 2025. Accessed July 18, 2025. www.ama-assn.org/about/leadership/action-must-follow-pledges-priorauthorization-reform
4. Holcombe D. Artificial intelligence, algorithms and abuse. Oncology Practice Management. February 2025. Accessed July 18, 2025. www.oncpracticemanagement.com/issues/2025/february-2025-vol-15-no-2/artificial-intelligence-algorithms-and-abuse
5. Bala M. Patient support and access strategy. June 24, 2025. Accessed July 18, 2025. www.linkedin.com/posts/maureenbala_thepoop-patientaccess-galwaygroupblog-activity-7343589321813225472-BR5Z/?utm_source=share&utm_medium=member_android&rcm=ACoAAADlRJgBjgsa7F1ynGvzy3M_dYaWyptr-Ts