Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services, talked about health plan prior authorization processes June 23 at an HHS press conference in Washington. Credit: HHS
Health insurers have agreed to provide new streams of data that will show how well they are improving health plan prior authorization processes, a top federal health official said Monday.
Dr. Mehmet Oz, the new administrator of the Centers for Medicare and Medicaid Services, and other CMS officials talked about the new prior authorization improvement data streams at a press conference that CMS and CMS' parent, the U.S. Department of Health and Human Services, held in Washington to unveil the prior authorization reform initiative.
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America's Health Insurance Plans, the Blue Cross and Blue Shield Association and the groups' member insurers have all signed on, and officials said about 50 insurers have already signed on.
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Participating insurers will send the prior improvement dashboards data on measures such as changes in the number of medical procedure codes subject to prior authorization processes and success at meeting prior authorization request response deadlines, CMS officials said.
Health insurers said they hope to respond to at least 80% of requests for prior authorization "in teal time" by 2027.
The dashboards will be available on the CMS website and on the AHIP website. AHIP and the Blues said insurers will start to report at least some of the data by Jan. 1, 2026.
"Transparency comes with accountability," Oz said. "We'll be able to audit if this is really happening. This is hard to do, and folks sometimes change their mind. We don't want that to happen, so we're going to trust but verify."
CMS: CMS is the division of the U.S. Department of Health and Human Services in charge of Medicare, Medicaid and Affordable Care Act programs that affect commercial health insurance.
CMS works with the Internal Revenue Service and the U.S. Labor Department's Employee Benefits Security Administration to oversee group health plans.
Priority authorization basics: Health plans use prior authorization processes to review patient requests for coverage for procedures such as MRI scans and heart operations and prescription drugs such as Wegovy and other expensive GLP-1 agonists.
Physicians have complained that the prior authorization review procedures can be slow and cumbersome, sometimes seem to be run entirely by computers, and sometimes seem to lack live-human reviewers who may lack the experience or training to understand the coverage requests.
Health insurers argue that prior authorization reviews are one of the few defenses they have against skyrocketing claim costs.
Employer plans: HHS did not have representatives from EBSA at the press conference.
Oz and the other speakers did not mention employer plans or the sponsors' need to avoid paying for unnecessary, overly expensive or potentially harmful care.
Cigna, Voya and Sun Life are examples of companies that have reported seeing an escalation in increases in employer plan costs in the past 18 months.
Sun Life, for example, said it saw 221 claims for $1 million or more per 1 million lives at employer plans it administered in 2024, up 29% from the $1 million claim rate for 2023.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
