Health Insurers Commit to Streamlining Pre-Approval Process

WASHINGTON – Health and Human Services Secretary Robert F. Kennedy Jr. announced on Monday that the leading health insurance company in the U.S. is planning to simplify the pre-certification process. This change aims to address the delays and denials of care that often frustrate patients.

Pre-authorization serves as a cost-saving measure for insurers, requiring patients to obtain approval for tests, procedures, or medications before they can access them.

Concerns over insurance practices were heightened last year following the tragic shooting of United Health Insurance CEO Brian Thompson in New York City.

Both patients and healthcare providers have consistently pointed out that these advance permissions complicate care access, sometimes resulting in waiting periods that stretch into days or weeks, or even outright denial of necessary services.

About one in every adult insured reports facing issues with prior approval, as highlighted in a survey conducted by KFF, a health policy research group.

Kennedy mentioned that numerous large insurers, such as the Blue Cross Blue Shield Association, Cigna, Elevens Health, Guidewell, Humana, Kaiser Permanente, and United Healthcare, have shown commitment to altering these practices across private insurance, Medicare Advantage, and Medicaid.

AHIP, a trade association for the health insurance sector, noted that these changes might benefit as many as 257 million individuals in the U.S.

However, experts have noted that prior approval requirements aren’t disappearing entirely.

“We’ve seen various changes attempted,” stated Dr. Adam Gaffney, a critical care physician and assistant professor at Harvard Medical School.

Insurance companies have made similar pledges before regarding prior authorizations. On Monday, both Kennedy and Dr. Mehmet Oz from the Centers for Medicare and Medicaid Services (CMS) were acknowledged at a media event for these efforts. Despite commitments made since 2018 and 2023 to reform the process, many insurers have yet to implement tangible changes, according to Oz.

When asked about the differences in this recent commitment, Oz remarked, “There’s violence on the streets over these issues.”

AHIP outlined the steps that health insurers have promised to take earlier this week.

Starting in the next year, if patients change their insurance plans during treatment, their new plan will honor existing prior approvals for similar care for up to 90 days. Additionally, insurers will be required to provide clearer explanations when they deny requests and offer guidance for appeals.

While the insurance companies claim to already follow some of these protocols, they’ve also committed to having a medical professional review and confirm any refusals for approvals.

Moreover, by 2027, insurers plan to simplify the pre-approval process by facilitating online submission of requests. They aim for at least 80% of electronic requests to receive responses in real time by that timeframe.

There’s potential for reducing the number of health services that require advance approval in various regions, but specific details on what that might entail remain vague.

Criskromp, who oversees the Medicare program at CMS, expressed hopes of lessening pre-authorization requirements for general services such as colonoscopies, cataract surgeries, and childbirth.

Kennedy also indicated that CMS will collaborate with insurers to simplify advance permissions for diagnostic imaging, physical therapy, and outpatient surgical procedures.

Dr. Gaffney, however, criticized this pledge, arguing that insurance companies have had ample time to reform their practices.

“The talk is cheap,” Gaffney stated. “More fundamental reforms will be necessary to truly eliminate the barriers to care imposed by insurance providers.”

Kaye Pestaina, director of KFF’s Patient and Consumer Protection Programme, suggested that some of the proposed commitments could directly benefit patients, particularly through honoring existing pre-authorization for up to three months after they switch their insurance plans.