Top officials in the Department of Health and Human Services (HHS) are touting a multipronged effort from major payers to reform the oft-criticized prior authorization process.
Mehmet Oz, M.D., administrator of the Centers for Medicare & Medicaid Services (CMS), said during a press conference Monday that the prior auth pledge is just the first step in a broader push. Oz and HHS Secretary Robert F. Kennedy Jr. met with major payers earlier in the day to discuss the commitments.
The roundtable included representatives from Aetna, CareFirst BlueCross BlueShield, Centene, Cigna, Elevance Health, GuideWell, Highmark Health, Humana, Kaiser Permanente and UnitedHealthcare as well as from AHIP and the Blue Cross Blue Shield Association.
Oz mentioned that for the Medicare Advantage program alone, which represents some 32 million beneficiaries, about 3.2 million claims were partially or fully denied in 2023.
He said that the executives present during the meeting made clear they supported prior authorization reform "to restore common sense to the process."
Oz also emphasized that the pledge is not a bill or a regulation.
"This is an opportunity for the industry to show itself. Participation is voluntary, but by the fact that three-quarters of the patients in the country are already covered by participants in this pledge, it's a good start, and the response has been overwhelming, gratifyingly so," Oz said.
Early Monday morning, insurers revealed the key elements of the pledge, which include commitments to reduce the number of codes that are subject to prior auth and to establish a framework that significantly increases how many authorizations are adjudicated electronically and in real time.
The insurers also said that as part of the pledge they will increase accountability and transparency around denials.
While prior auth has been a long-term headache for many physicians and patients, criticism of the practice has ramped up in the months following the murder of UnitedHealthcare CEO Brian Thompson last December. The bullets that were used in the shooting reportedly had "deny," "delay" and "depose" written on them.
When asked what incentives would hold insurers to the pledge, Oz acknowledge the public outcry that came after Thompson's death.
"There's violence in the streets over these issues," Oz said. "This is not something that is a passively accepted reality anymore. Americans are upset about it."
Oz also added that while the White House isn't taking regulatory action Monday, should insurers fail to meet the moment—and their commitments—the CMS and the HHS could use the levers at their disposal to pressure them further.
Also present at the press conference were Sen. Roger Marshall, M.D., R-Kan., and Rep. Greg Murphy, M.D., R-N.C., both of whom are physicians. Marshall and Murphy have long pushed for prior auth reform in Congress, and is a sponsor of the Improving Seniors' Timely Access to Care Act.
Marshall said legislators are absolutely still looking to take action around prior auth.
"I do think we owe it to our patients to go ahead and codify something," Marshall said.
In addition to commentary from regulators, multiple insurers that have signed on to the pledge made statements Monday.
"The American health care system must work better for people, and we will improve it in distinctive ways that truly matter," Aetna President Steve Nelson said in a statement. "We support the industry's commitments to streamline, simplify, and reduce prior authorization. We will go beyond prior authorization, building a health care experience for people we serve, and introducing solutions that improve navigation and advocacy for Aetna members."
Humana CEO Jim Rechtin echoed the sentiment.
"Humana is pleased to join with AHIP, the Blue Cross Blue Shield Association, and other health plans in making new commitments to streamline, simplify, and reduce prior authorizations," Rechtin said in a statement. "We are committed to supporting and building on this effort to make prior authorization faster and more seamless for providers and patients alike.”