5 Key Takeaways From Health Insurers’ New Prior Authorization Reform Pledge | Health Insurance Prior Authorization Changes | Medicare & Medicaid Updates

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Background: Insurance Industry Pledges to Improve Prior Authorization Process

In response to growing public concern and a tragic incident involving the shooting of an insurance CEO, major U.S. health insurers including Cigna, Aetna, Humana, and UnitedHealthcare have pledged to reform their prior authorization systems. These reforms aim to reduce delays and denials that have long frustrated patients and healthcare providers by streamlining approvals and improving transparency.

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1. Prior Authorization Will Remain a Part of Healthcare

Despite promises of reform, insurers will continue to use prior authorization as a tool to review and potentially deny doctor-recommended care. The new pledge does not eliminate prior authorization but promises fewer procedures will require it, and faster reviews.

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2. Reform Efforts Build on Existing Laws and Rules

Many states already have laws to limit delays caused by prior authorization and to promote transparency. Federal rules, established under the Trump and Biden administrations, will require insurers to process requests electronically and respond within strict timeframes starting next year. Some insurers have also made voluntary commitments prior to this pledge.

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3. Many Changes Are Already Required, But Enforcement Varies

Insurers are supposed to communicate clearly with patients about coverage decisions and have medical professionals review denials, but critics argue these standards are not always met in practice. Denial letters often remain confusing, and rapid automated denials raise concerns.

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4. Increased Use of Artificial Intelligence in Prior Authorization

Insurers plan to expand the use of AI to process prior authorization requests more quickly, targeting 80% real-time decision-making by 2027. While AI could improve efficiency, physicians worry it may increase denials without sufficient oversight.

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5. Important Details and Enforcement Mechanisms Are Still Unclear

Officials announced insurers will publicly share prior authorization data and performance goals, but timelines and enforcement plans remain vague. Patient advocates stress the need for concrete actions to ensure the pledge leads to meaningful improvements.