HHS and CMS Secure Industry Pledge to Reform Broken Prior Authorization System
HHS Secretary Kennedy, CMS Administrator Oz Secure Industry Pledge to Fix Broken Prior ...
Summary
The U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) announced six key reforms with industry leaders, aiming to streamline the prior authorization process for Americans' care.
Details
On June 23, 2025, HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz met with industry leaders to discuss improving the prior authorization processes for Medicare Advantage, Medicaid Managed Care, and commercial plans. The participating health insurers pledged six key reforms: first, standardizing electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based APIs. Second, reducing the volume of medical services subject to prior authorization by January 1, 2026. Third, honoring existing authorizations during insurance transitions for continuity of care. Fourth, enhancing transparency and communication regarding authorization decisions and appeals. Fifth, expanding real-time responses, aiming for real-time approvals for most requests by 2027. Sixth, ensuring that medical professionals review all clinical denials. These private sector reforms complement ongoing regulatory efforts by CMS to improve interoperability within Medicare Advantage and Medicaid Managed Care, emphasizing a patient-first approach while maintaining accountability through continuous evaluation.
Original content copyright by respective publishers