Through AHIP, Payers Vow to Rein in Prior Authorization, but Doctors Have Doubts

Forty-eight health insurers have pledged to “streamline, simplify, and reduce” prior authorizations (PAs), a process that requires payer clearance before patients gain access to care, whether it’s a test, procedure, or prescription drug. The commitment, coordinated through the trade association America’s Health Insurance Plans (AHIP), was announced on July 23, 2025, in Washington, DC, following a meeting with HHS Secretary Robert F. Kennedy Jr and CMS Administrator Mehmet Oz, MD, MBA.1,2

Mike Tuffin | Image: AHIP

Plans adopting the pledge include more than 30 Blue Cross Blue Shield entities, as well as large national insurers including UnitedHealthcare, Humana, the Cigna Group, and CVS Health Aetna. Centene, the largest Medicaid insurer, is also participating.1

The pledge comes as physicians from different regions and specialties have complained that PA constraints are worse than ever, are interfering with patient care, and have contributed to burnout among providers.3,4

Consumers experience PA challenges when they cannot take a prescribed drug to treat cancer or get a needed scan to guide care. Sometimes, patients must make their own appeals—and increasingly, they may use artificial intelligence to do so.5

Following the pledge, KFF published a poll on July 25, 2025, that found 73% of consumers find that PA requirements are both challenging to navigate and increasingly uncommon, and 51% reported dealing with a PA issue in the previous 2 years.6

Insurers say they require PAs to ensure that all care is medically necessary and cost-effective. From their view, PAs prevent unnecessary procedures and medications, ensuring patient safety and holding down overall costs.7 However, providers and patients say cost has become the overriding priority, and that the process has harmed patients. In 2023, an American Medical Association (AMA) survey found that 1 in 3 doctors could attribute at least 1 adverse event to PA delays.8

On July 18, 2025, the New York Times published an investigation that found medical claim denials rose 25% from 2016 to 2023, following an analysis of more than 4 billion claims by Komodo Health.9 The analysis attributed many denials to actions by pharmacy benefit managers (PBMs), the largest of which are controlled by the nation’s major insurers: UnitedHealth Group (Optum Rx), CVS Health Aetna (CVS Caremark), and Cigna (Express Scripts).

The AHIP statement said the insurers’ commitments would apply to Medicare Advantage, Medicaid, and commercial plans and would affect 257 million Americans. Promises include adhering to a common set of technology standards, ensuring continuity of care if a patient changes plans, and scaling back what is covered by PAs.1

Bipartisan support is growing in Congress to restrict PAs, especially in Medicare Advantage plans. In May, the AMA announced support for a bill that would require “true peers” to make decisions. This change would be especially relevant for specialty fields such as oncology, where there are frequent complaints that insurer representatives lack knowledge of current guidelines or recent scientific advances.10

Some states are acting on their own to address PA problems. A New Jersey law that took effect in January reduces the time insurers have to make PA decisions and requires urgent medication requests to receive action within 24 hours.11

The AMA offered cautious praise for the announcement in a statement from Bobby Mukkamala, MD, the association’s president. He noted that health plans pledged in 2018 and in 2023 to act on PA complaints, but physicians do not see progress.12

Bobby Mukkamala, MD | Image: AMA

“We are pleased with the industry’s recognition that the current system is not working for patients, physicians, or plans,” Mukkamala said in a statement.12 “However, 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.

“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.”12

The Community Oncology Alliance (COA) has maintained an online archive of patient encounters with both PA and PBM restrictions, which are especially problematic in oncology, as delays of even a few weeks can allow cancer to progress.13 Debra Patt, MD, PhD, MBA, the current COA president, has testified before Congress about PA and PBM abuses.14 In a recent interview, COA Executive Director Ted Okon said he was taking a wait-and-see approach to the latest pledge.

In making their pledge, insurers said recent technological improvements may finally bridge the gaps physicians and practices experience. Specifically, the AHIP pledge calls for the following1:

Technology standards. The pledge sets a goal of January 1, 2027, for health plans to develop standardized data and submission requirements using Fast Healthcare Interoperability Resources (FHIR) application program interfaces (APIs) that will lead to faster turnaround times.

Fewer claims covered. Plans will curtail the number of claims that require PA, based on the local market, by January 1, 2026.

Continuity of care. When a patient’s insurer changes during a treatment course, the new plan will honor existing PAs for benefit-equivalent in-network services for 90 days. This takes effect on January 1, 2026. Patients covered by employer-based plans typically have no control over a change in insurer.

Communication and transparency. The pledge calls for plans to provide “clear, easy-to-understand explanations of [PA] determinations, including support for appeals and guidance on next steps.”1 This will take effect on January 1, 2026, for commercial plans; the plans call for regulatory changes to include other plan types, such as Medicare Advantage.

Real-Time Responses. With the adoption of FHIR APIs, the plans call for at least 80% of electronic PA approvals by 2027. Clinical documentation is required.

“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike. Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care while also helping to modernize the system,” Mike Tuffin, AHIP president and CEO, said in a statement.1

The Blue Cross Blue Shield Association will work with AHIP to track and report progress.

“These measurable commitments—addressing improvements like timeliness, scope, and streamlining—mark a meaningful step forward in our work together to create a better system of health,” Kim Keck, president and CEO of Blue Cross Blue Shield Association, said in the statement. “This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience.”1

AHIP said information on plan progress will be tracked on the following sites: www.ahip.org/supportingpatients and https://www.bcbs.com/ImprovingPA.

References
1. Health plans take action to simplify prior authorization. News release. AHIP. June 23, 2025. Accessed July 25, 2025. https://www.ahip.org/news/press-releases/health-plans-take-action-to-simplify-prior-authorization
2. HHS Secretary Kennedy, CMS Administrator Oz secure industry pledge to fix broken prior authorization system. News release. HHS. June 23, 2025. Accessed July 25, 2025. https://www.hhs.gov/press-room/kennedy-oz-cms-secure-healthcare-industry-pledge-to-fix-prior-authorization-system.html
3. Henry TA. Prior authorization delays care—and increases health care costs. American Medical Association. August 12, 2024. Accessed July 25, 2025. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-delays-care-and-increases-health-care
4. McCormick B. AMA survey highlights growing burden of prior authorization on physicians, patients. AJMC. February 24, 2025. Accessed July 25, 2025. https://www.ajmc.com/view/ama-survey-highlights-growing-burden-of-prior-authorization-on-physicians-patients
5. Morgenson G. AI helping patients fight insurance company denials. NBC News. July 18, 2025. Accessed July 25, 2025. https://www.nbcnews.com/news/us-news/ai-helping-patients-fight-insurance-company-denials-wild-rcna219008
6. Sparks G, Montalvo J, Schumacher S, Kirzinger A, Hamel L. KFF Health Tracking Poll: Public finds prior authorization process difficult to manage. KFF. July 25, 2025. Accessed July 25, 2025.
7. What is prior authorization? Healthinsurance.org. Accessed July 25, 2025. https://www.healthinsurance.org/glossary/prior-authorization/
8. O’Reilly KB. 1 in 3 doctors has seen prior auth lead to serious adverse event. March 29, 2023. Accessed July 25, 2025. American Medical Association. https://www.ama-assn.org/practice-management/prior-authorization/1-3-doctors-has-seen-prior-auth-lead-serious-adverse-event
9. Kliff S. Health insurers are denying more drug claims, data shows. The New York Times. July 18, 2025. Accessed July 25, 2025. https://www.nytimes.com/2025/07/18/health/health-insurance-prescription-claim-denials.html
10. Henry TA. Prior authorization bill would require true peers make decisions. American Medical Association. May 15, 2025. Accessed July 25, 2025. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-bill-would-require-true-peers-make
11. New prior authorization laws to go into effect in 2025. New Jersey Association of Mental Health & Addiction Agencies. January 3, 2025. Accessed July 25, 2025. https://www.njamhaa.org/2025-01-03-new-prior-authorization-laws-to-go-into-effect-in-2025
12. AMA responds as health insurers try again on prior authorization reform. American Medical Association. June 24, 2025. Accessed July 25, 2025. https://www.ama-assn.org/press-center/ama-press-releases/ama-responds-health-insurers-try-again-prior-authorization-reform
13. PBM horror stories. Community Oncology Alliance. Accessed July 25, 2025. https://mycoa.communityoncology.org/education-publications/pbm-horror-stories?pa
13. Patt D, Caffrey M. COA President Patt promotes advocacy: “each of us holds an important part of the story.” Am J Manag Care. 2025;31(2):SP109-SP111.