Prior authorization has long been a sticking point between payers and providers, with payers arguing that it’s necessary to control costs and ensure that care is medically necessary and providers arguing that it creates administrative burden and delays care.
Regardless of who’s right in this debate, it’s clear that the practice is in desperate need of improvement. That’s why in June, more than 50 health plans — such as UnitedHealthcare, Aetna, Cigna and several Blues plans — made a series of commitments in partnership with the Centers for Medicare and Medicaid Services to simplify prior authorization, including providing more clear explanations of prior authorization determinations, increasing turnaround times for determinations and ensuring continuity of care when patients switch plans. Several of these commitments will go into place in 2026, while others will take effect in 2027.
“We’re making meaningful progress on improving the prior authorization process. … With many improvements going live in January, we remain committed to streamlining processes and reducing the scope of requirements to improve the experience for patients and providers,” a Blue Cross Blue Shield Association representative who declined to be named told MedCity News.
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Still, the question remains of whether these commitments will be enough for providers, who generally seem cautiously optimistic about the commitments.
“Any step toward reducing prior authorization is welcome, and family physicians have been asking for relief for years,” said Dr. Jen Brull, board chair of the American Academy of Family Physicians. “From where we sit in exam rooms, commitments alone aren’t sufficient. Prior authorization still eats up an enormous amount of time and causes real delays in care; nearly 90% of physicians say it’s extremely burdensome. Until we see meaningful changes that actually reduce paperwork and speed up approvals, patients and physicians will continue to feel the strain.”
Beyond these commitments, 2025 has seen additional developments in the prior authorization landscape, including the introduction of the WISeR Model, which extends prior authorization requirements into traditional Medicare. In 2026, experts will also be watching out for developments in the Improving Seniors’ Timely Access to Care Act, which would streamline prior authorization in Medicare Advantage.
What are the commitments in 2026?
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According to AHIP’s announcement in June, the commitments going into effect in 2026 are:
- Reducing the scope of claims subject to prior authorization: The insurers will reduce prior authorization requirements for certain claims, which will depend on the market each plan serves. These reductions are expected to start January 1, 2026.
- Ensuring continuity of care when patients switch plans: When patients switch insurance plans during treatment, their new insurer must honor existing prior authorizations for similar in-network services for 90 days to ensure continuity of care and prevent delays. This will begin January 1, 2026.
- Improving communication and transparency on determinations: The insurers pledge to give clear explanations of prior authorization determinations, as well as information on appeals. This will be available for fully insured and commercial coverage by January 1, 2026.
In 2027, payers will focus on standardizing electronic prior authorization and expanding real-time responses. Insurers anticipate that at least 80% of electronic prior authorization approvals will be answered in real-time.
In total, 53 plans signed all of these commitments, including the biggest names in the world of healthcare insurance: UnitedHealthcare, Elevance Health, Aetna, Cigna, Kaiser Permanente, Centene, Humana, Highmark and several Blues plans.
AHIP Spokesperson Chris Bond told MedCity News that progress will be tracked and reported publicly. The organization anticipates that the first report will come in the spring of 2026.
Several payers told MedCity News that they’re on track for the commitments in 2026. Dr. Muhannad Hammash, corporate vice president of medical policy at SCAN Health Plan, said the nonprofit Medicare Advantage insurer has been working closely with its provider partners to ensure readiness, including hosting an October summit to review the commitments and holding one-on-one meetings with individual groups to help them understand and prepare for the changes.
That said, there are challenges to getting these commitments in order. For example, meeting the 2027 commitment for electronic prior authorization will require a substantial effort to support providers that currently lack the technology infrastructure and resources needed to submit prior authorization requests electronically.
“Some of these technologies are expensive, especially for smaller groups,” Hammash said. “That’s one of the challenges we have to look into and see what is the best way we can work with those providers in resolving these issues, because we have to move from the traditional way of paperwork and faxes to using technology that would help us speed up the process.”
An executive at Blue Shield of California echoed the need for more advanced technology to ensure these commitments work.
“Health plans will need to leverage their internal intelligence about members, policies, benefits, and networks to facilitate automatic approvals at scale,” said Dr. Laurine Tibaldi, vice president of medical management at Blue Shield of California. “We will hopefully see more providers increase their use of technology to communicate with health plans wherever possible – in place of faxes or phone calls. More real-time communications between health plans and providers will help patients get care faster and reduce stress for everyone involved.”
Aetna President Steve Nelson told MedCity News that the insurer is working to fulfill these commitments and shoot even higher. For example, it announced in December that it is bundling medical procedures and pharmaceutical medications into one prior authorization. Previously, providers had to submit two separate prior authorizations for medical procedures and related medications. In addition, the insurer is working on bringing more transparency into the process.
“One of the frustrations about prior authorization is you don’t know where you are in the process,” Nelson said in an interview. “We’ve added capabilities in a digital app so you can now know where you are in the process. Is it pending? Has it been denied? What’s the next step? Has it been approved? What’s going on with it?”
Will this be enough for providers?
While physicians are generally optimistic about these commitments, it goes without saying that there’s a little skepticism as well.
To hold payers accountable, Brull said providers should make sure to document delays, denials and inconsistencies and bring those concerns to lawmakers.
A Medicare policy expert at consulting firm McDermott+ — Lynn Nonnemaker — noted that the skepticism among providers is both “appropriate and healthy,” and this skepticism will play a role in ensuring that plans follow through. She added that CMS Administrator Dr. Mehmet Oz has said that the agency is prepared to act if plans don’t follow through.
“Certainly, CMS could go further in restricting plans’ use of prior authorization,” she said in an interview. “One important thing that CMS can do is serve as a convener in helping bring about more standardization of the systems and processes that plans use and the way that providers interact with them.”
Although the onus is on the insurers to carry out these commitments, providers can also take their own steps to improve prior authorization, Nonnemaker’s colleague noted.
“It takes two to tango,” said Jeffrey Davis, a director at McDermott+. “So if the payers want to automate the process, that means the provider side will have to have the technology in place, the systems in place, to handle those automated transactions. Providers have to buy into this too and set up their systems. Payers can do all they want on their side, but if the providers don’t participate, there’s not going to be a seamless prior authorization process.”
An executive at GuideHealth, a tech-enabled value-based care services company, echoed this.
“Providers can improve outcomes by standardizing submissions, using structured clinical data, and aligning with evidence-based pathways in collaboration with payers,” said Sanjay Doddamani, founder and CEO of GuideHealth, in an email. “Treating prior auth as a shared clinical and operational workflow, rather than a downstream administrative task, is key to reducing friction.”
Beyond these commitments, Brull is hopeful that there will be movement on the Seniors’ Timely Access to Care Act, which would streamline prior authorization in Medicare Advantage.
“The House has already passed it once, and we’re working hard to get it across the finish line,” she said. “At the end of the day, prior authorization should never stand between a patient and timely care, and physicians should be able to focus on caring for patients, not paperwork.”
This is a burden felt by most physicians, as 94% reported in an American Medical Association survey that prior authorization causes major delays in necessary care. There’s an economic reason for reducing prior authorization as well. According to a study published in Health Affairs, drug prior authorization costs $93.3 billion annually, including $6 billion for payers, $24.8 billion for manufacturers, $26.7 billion for physicians and $35.8 billion for patients.
Given the burden of prior authorization, Brull is also concerned about some moves that CMS is taking that can have a worrying impact. She said that new innovation models could “reintroduce prior authorization under different names or mechanisms, which means practices have to stay vigilant just to keep patient care moving.”
For instance, in June, CMS Innovation Center introduced the WISeR model (Wasteful and Inappropriate Service Reduction Model), that brings a prior authorization process into traditional Medicare in an effort to reduce “fraud, waste and abuse.” This is concerning to Brull as traditional Medicare has “long been free from those hurdles.” This could slow care for seniors and add more administrative challenges to practices, she said.
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