Health insurance prior authorizations get a facelift: What consumers should know

According to the Kaiser Family Foundation, a nonprofit health insurance organization, 16% of insured adults have experienced prior authorization problems within the past year. However, federal changes coming in 2027 promise a smoother process, offering hope for efficiency and transparency you when you head out to the drug counter or the doctor’s office.

Prior authorization explained

Prior authorization is a process sometimes required by insurance carriers when a procedure or drug is recommended by a health care provider. In order for a patient to receive that care, equipment, or drug, the plan will decide if the care is medically necessary before they will approve and cover it. This practice most often is applied for things like diagnostic imaging, durable medical equipment (think wheelchairs and lifts), inpatient procedures, and various home health care options.

According to the American Medical Association, the average physician fills 45 prior authorization requests per week, taking up an average of 14 hours per week.

Streamlining the Process

The Centers for Medicare and Medicaid Services (CMS) have introduced a final regulation to standardize prior authorizations across various health insurance programs, including Medicaid, Medicare Advantage, and ACA Marketplaces. This signifies more consistent rules and better access to information for patients and providers alike.

Here’s what will be different

The new rule requires everyone involved to make prior authorization data electronically available. This should, in theory, enhance efficiency and accessibility for those involved with patients. By making the information available to stakeholders at the push of a button, it will now be easier for providers to manage their patients. But that’s not star of the show: prior authorization decisions should now be much faster.

However, this is only the case if everyone involved in the process is on board. Patients need the know-how to navigate digital platforms effectively, and every provider needs to participate if these faster decisions are going to come to fruition.

And faster they shall have to be. Standard decisions must now be made within seven calendar days, and expedited ones must be made within 72 hours. This is half the current 14 day standard for Medicare Advantage plans.

Who is to benefit?

New transparency requirements give patients, providers, policy-makers and researchers clearer insight into how prior authorization works in the real world. Payers must now provide the information used to make a prior auth available through four different applications. These four applications must reach the patient, the provider, and any payers involved.

Sharing information will help all parties involved understand why a decision was made. Loads of questions will now be easily answered by publicly available data. What plans are requiring prior authorizations? What services are getting hit with them? What information is getting asked for? What does the denial atmosphere look like? Lots of people will stand to gain something from understanding the whats and whys behind the decision making process.

The only data that will not be made available is the specific types of services that are being denied. Which brings us to our next topic…

What’s left to improve

Since some of the heaviest details will be omitted from this the transparency requirements, it could be easy to hide. Those who make the decision, and the things they decide, are still shrouded in darkness. We won’t be able to glean from the data things like what services are being denied most often and the reasons why these exclusions are being made.

The use of this software is not required. Therefore, patients or providers who choose not to take advantage of this system improvement will not reap the benefits. Consumers can also choose to opt out of this completely. CMS does plan to track consumer use of the software used to communicate the data, which might also communicate other things.

And even if a provider does want to participate, they will most likely need to enlist a third party software to do the heavy lifting.

Most employer-sponsored health plans are also exempt from this rule, so a good chunk of Americans might feel left out.

What else to look out for

Excluding prior authorization, there are other forces patients might grapple with for prescription drugs and care access. Issues like step therapy and claim review timing persist, potentially impacting timely treatment. Addressing these concerns will require future rulemaking.

Despite progress in standardizing prior authorization, these will only apply to Medicare, Medicaid, and those plans purchased on the ACA. Those who get coverage from their work might not enjoy the same standards as those who must follow this rule.

Challenges remain, including accessing and interpreting this data. If the data isn’t shared in a usable or digestible format, it’ll be tough for patients and providers alike to do anything meaningful with it. As of now, there is no regulation surrounding how this data is shared.

Looking Ahead

Some gaps still exist, but these regulatory changes offer hope for a smoother prior authorization experience. As the required information gets shared and due dates are enforced, both providers and patients should experience less time waiting for a prior authorization, which means quicker care and better health outcomes.