What providers really need to streamline prior authorizations

From 30,000 feet to ground level

The issue isn't necessarily that payers aren't doing enough, but that the impact of their commitments after a year has yet to trickle down to practicing providers.

"You see this a lot in healthcare policy; it's theory versus practice," Drevna said. "We've altered the arrangements at the 30,000-foot level, but by the time it gets down to the clicks with the clinician in front of the patient, that takes a long time."

That's why America's Health Insurance Plans, which sponsors the pledge, has emphasized the multi-year aspect of the commitment. In fact, the signatories have prioritized two goals this first year -- reducing the scope of services subject to prior authorizations and ensuring continuity of care. Participating plans will focus more on implementing a standardized, electronic transaction in January 2027.

AHIP and the Blue Cross Blue Shield Association previewed the standardization effort in April, saying it will apply to medical services commonly subject to prior authorizations, such as orthopedic surgeries and imaging services.

AHIP's president and CEO Mike Tuffin said at the time that this effort, which will happen on a rolling basis next year, will speed up the process and reduce friction for payers, providers and patients.

Signatory plans also plan to implement enhanced communication strategies at the beginning of next year, according to AHIP. They also aim to achieve at least 80% of prior authorization approvals in real time across all coverage types in 2027.

Despite concrete timelines, many providers remain skeptical about the health plans' progress on their commitments. Recent reports have called the pledge performative, saying it continues to delay affordable access to care for vulnerable patients and lacks the teeth for meaningful change.

Drevna said that prior authorizations remain a "really personal and painful" issue for medical groups. To this day, the industry insider hears stories from AMGA members about the frustrations and burdens associated with the process.

These issues aren't getting better either, despite leading payers publicly sharing their plans and progress. For example, the growing demand for GLP-1s has added to medical groups' prior authorization burdens. Payers seek to manage utilization for newly released therapeutics, further adding to providers' burden, according to Drevna.

Translating providers' stories into progress

One of AMGA's top priorities is to translate these stories into policy that improves its members' lives. As such, the industry group is pushing for enforceable deadlines for payers to make a prior authorization determination.

Drevna said the group would like to see similar turnaround times proposed by the Centers for Medicare and Medicaid Services for prescription drugs. Those times, when the rule is finalized, would be 72 hours for standard requests and 24 hours for expedited requests. They would apply to federally regulated health plans, such as those sold through the Affordable Care Act Marketplace.

If a payer fails to make a determination within that period, Drevna suggested, it should default to an approval, especially since overturn rates on prior authorization denials tend to be so high. That rate is as high as 80% in Medicare Advantage, according to KFF.

This approach provides the push some say payers need to really move the needle with prior authorization progress, even though real-time responses are part of the commitments major payers made to improve the process.

AMGA would also like to see more gold-card programs that exempt certain providers from prior authorization requirements, allowing them to bypass reviews for specific medical services based on their approval rates.

Implementing gold-card programs isn't explicitly stated in the AHIP-sponsored commitments. However, some of the signatory plans, including Cigna and UnitedHealthcare, have used this strategy to reduce the scope of services subject to prior authorization requirements.

For instance, AHIP reported that UnitedHealthcare's gold-card program has reduced total requirements across more than 500 codes, including those for primary care and oncology, cutting the volume of requests by an average of 30% for eligible provider groups.

Additionally, AMGA is advocating for payers to provide specific explanations for prior authorization denials, "not just a boilerplate reason," Drevna said.

"That doesn't give us something we can work with to come back and say, 'Oh, okay, you denied it for this reason,' and we either provide the additional information you needed or understand why we're going down this path," he explained.

Signatory plans committed to "explaining with clear and personalized language about any prior authorization denials, including information about next steps and available appeals processes" by the start of this year. However, many of the plans have focused on improving member communications, leaving providers to figure it out on their own.

Better provider communications, gold-card programs and deadline enforcement are all top-line reforms AMGA providers would like to see to decrease the burden of prior authorizations. But Drevna stressed that meaningful progress will require candid conversations between payers and providers to bridge the gap between what payers are doing and what providers want.

"These things take time, and slowly but surely we're going to get there -- not quick enough in our members' opinion, but it's definitely a positive development," he said. "We just need to see it translate to actual change."

Jacqueline LaPointe is an Executive Editor at Xtelligent Healthcare Media, covering revenue cycle management, healthcare payers, health policy and health IT since 2016.