On June 23, HHS Secretary Kennedy and CMS Administrator Dr. Mehmet Oz held a roundtable with health insurance companies to discuss a new pledge to "streamline and improve the prior authorization processes for Medicare Advantage (MA), Medicaid Managed Care, Health Insurance Marketplace and commercial plans." Endorsed by a number of private health plans, the pledge includes six key reforms:
- Standardizing electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces.
- Reducing the scope of claims subject to prior authorization by January 1, 2026.
- Ensuring continuity of care by honoring existing authorizations for up to 90 days during insurance transitions.
- Enhancing transparency and communication around authorization decisions and appeals.
- Expanding real-time responses to 80 percent of electronic prior authorization requests by 2027, to minimize delays in care.
- Ensuring medical professionals review all clinical denials.
Many of the elements of the pledge are either already required, already happening, or are things that payors have sought in the past. Despite this, the announcement underscores the Administration's interest in continuing to encourage "private sector reforms" that may be complementary to the Administration's regulatory agenda, noting that HHS and CMS may "pursue additional regulatory actions if necessary."
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