With state and federal policymakers eyeing restrictions on health insurers’ use of the care-delaying cost-control process of prior authorization, the nation’s biggest carriers are pledging anew to make changes on a voluntary basis. 

The AMA has been a relentless, powerful advocate for fixing prior authorization—challenging insurance companies to eliminate care delays, patient harms and practice hassles. The AMA’s most recent survey (PDF) of physicians shows how prior authorization is blocking lifesaving treatments, and the AMA is tracking state laws (PDF) and offers model state legislation (PDF). 

In a statement issued last month in response to the insurers’ announcement, AMA President Bobby Mukkamala, MD, said the proposals “would help right-size and streamline a process that is harming our patients daily.”  

He added that “the announced reforms are ones the AMA has long advocated for to policymakers and echo commitments health plans previously agreed to in the 2018 consensus statement on improving the prior authorization process [PDF], including reducing the volume of prior authorization requirements, protecting care continuity as patients transition to new health plans, improving transparency, and automating the process. 

“Despite widespread calls for meaningful reforms and the insurance industry’s past promises, the prior authorization process remains costly, inefficient, opaque, and too often hazardous for patients,” said Dr. Mukkamala, a Flint, Michigan, otolaryngologist who must navigate prior authorization as a physician and as a patient. “That is why the AMA enthusiastically supported recent federal regulations that applied reforms to limited health insurance markets, including Medicare Advantage.  We are optimistic that health plans’ pledge to expand the scope of several of these important reforms to other insurance types will provide more patients and physicians with relief.” 

The health insurer trade group AHIP and the Blue Cross Blue Shield Association announced the planned changes in late June. Health and Human Services Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet C. Oz, MD, highlighted the leadership role that the Trump administration played in convening the health insurance industry for this effort in a related news conference. 

At this article’s deadline, more than 60 health insurers had committed to actions that AHIP says “will make health care faster and simpler.” Here are the six steps they have announced. Of note, several of the pledged actions (for example, standardized electronic prior authorization and improved communication on denials) are mirrored in recent CMS final rules. This gives CMS the oversight and authority to enforce follow-through on these commitments for federally regulated plans. 

The health plans that have signed on “will work toward the development and implementation of common, transparent submissions for electronic prior authorization. This commitment includes the development of standardized data and submission elements” by using Fast Healthcare Interoperability Resources Application Programming Interfaces (FHIR APIs). These tech elements “will support seamless, streamlined processes and faster turnaround times.”  

Goal date: Jan. 1, 2027. 

The health plans that have signed on and provide fully insured, Affordable Care Act (ACA) marketplace and Medicare Advantage coverage say “they will individually reduce the volume of in-network medical prior authorizations.” 

However, such changes will be done “as appropriate for the local market each health plan serves,” the AHIP pledge says. “This commitment is consistent with health plans’ ongoing efforts to regularly review and adjust their prior authorization lists based on current data and their enrollees’ needs.” 

Goal date: Jan. 1, 2026.  

Payers are committing “to support continuity of care by honoring a previous health plan’s prior 

authorization for the same service, under the same type of benefit in network for a 90-day transition period when a member changes health plans after starting a course of treatment,” says the AHIP document, “Improving Prior Authorization for Patients & Providers.”  

Health plans will honor the previous carrier’s prior authorization “provided that item, service or medication is a covered benefit under the new health plan with an in-network provider.”  

Goal date: Jan. 1, 2026. 

For fully insured and self-insured commercial coverage and ACA marketplace coverage, payers are committing to explain “with clear and personalized language about any prior authorization denials, including information about next steps and available appeals processes.”  

The health plans say they will explore regulatory changes “to facilitate expansion of this commitment,” and Medicare Advantage plans “will work with CMS to improve existing mandatory member communications on prior authorization denials and appeals.” The carriers also “commit to providing staff to help members understand the prior authorization process and their options after a prior authorization determination is made.” 

Goal date: Jan. 1, 2026. 

The health plans that have signed on are committing “to an acceleration of the percentage of prior authorization requests for medical services answered in real-time if submitted electronically by providers with all necessary clinical documentation.”  

AHIP notes that “existing regulations require new technical standards for electronic prior authorization for certain health plans in federal programs.” The payers that have signed on and are subject to the new federal rules will aim to do the same across all lines of business: “for all coverage types, at least 80% of prior authorization approvals will be answered in real time.”  

Goal date: Jan. 1, 2027. 

Signatory plans say “that all prior authorization denials based on medical necessity for clinical factors will be reviewed by a licensed and qualified clinician.” 

Goal date: “This commitment reflects existing practices and is in effect now,” AHIP says. 

In his statement, Dr. Mukkamala said that while it is a positive sign that the health insurance industry is starting to recognize “that the current system is not working for patients, physicians or plans,” the AMA will be scrutinizing implementation meticulously.  

“Patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions to bring immediate and meaningful changes, break down unnecessary roadblocks, and keep medical decisions between patients and physicians,” Dr. Mukkamala said. “The AMA will closely monitor the implementation and impact of these changes as we continue to work with federal and state policymakers on legislative and regulatory solutions to reduce waste, improve efficiency, and, most importantly, protect patients from obstacles to medically necessary care.” 

Notably, the health plans’ proposals do not address prior authorization in prescription-drug benefits, are limited to certain health-plan products, and reflect just a subset of the comprehensive set of reforms that the AMA has long advocated. That is why Dr. Mukkamala also stressed the need to continue the push for state and federal legislative and regulatory reforms to codify these changes into law and expand upon them to further increase access to care for all patients. Read his latest AMA Leadership Viewpoints column, which explains why action must follow pledges on prior authorization reform.  

Learn more with the AMA about the critical changes that are needed to fix prior authorization by: 

Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on. 

Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.