Prior Authorization Overhaul: Insurers Respond to Growing Outrage
Health insurers prior authorization rules face overhaul as UnitedHealthcare, Aetna pledge faster, simpler approvals. This is a huge milestone for healthcare access.
Following UnitedHealthcare CEO Brian Thompson’s shooting death, which sparked further criticism of the company’s restrictive insurance policies, the new pledges were made.
What Does Prior Authorization Mean and Why Is It a Big Deal?
Prior permission from the insurance company is required before patients may get certain tests, medications, or treatments. Insurers argue it reduces usage, but doctors and patients believe it has become a major barrier to timely care.
“There’s violence in the streets over this,” said Dr. Mehmet Oz, head of the Centers for Medicare and Medicaid Services (CMS), at a press conference Monday.
Promised Reforms by Insurers
Insurers announced several key changes:
- Reduce the number of services requiring prior authorization
- Standardize electronic forms and submissions by end of 2026
- Honor prior authorizations from previous insurers after plan changes
- Expand real-time claim responses
- Ensure medical reviews for clinical denials (though not necessarily by specialists)
Despite these promises, Dr. Oz warned regulations may follow if progress stalls:
“You fix it or we’re going to fix it.”
Why This Matters: Patient Harm & “Scanxiety”
Doctors warn that delays caused by prior authorization—even when requests are eventually approved—can worsen medical outcomes. For patients, the emotional toll is just as real.
“There’s a term we use called scanxiety,” said Dr. Ashley Sumrall, a brain tumor oncologist. “These delays can be dangerous.”
Medicare Advantage & Denial Rates
A 2023 study by KFF found:
- Nearly all Medicare Advantage enrollees required prior authorization for some services
- About 6% of requests were denied
- Imaging, hospital stays, and specialty drugs were most impacted
Sumrall emphasized the chaos of different rules:
“Every insurer has their own way of doing business.”
Will These Promises Apply to Everyone?
Yes—insurers say the changes will apply to:
- Employer-sponsored plans
- Individual marketplace coverage
- Medicare Advantage
- Medicaid
While many remain skeptical, advocacy groups and doctors cautiously welcome the move toward standardization.
Source: AP News
