Health Insurers Pledge to Fix Prior Authorization System for HHS, CMS
Health insurers tell HHS, CMS they'll fix prior authorization system - InsuranceNewsNet
Summary
A group of major health insurers pledged to streamline and improve the prior authorization process to the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS). This effort aims to provide patients with faster access to appropriate care and allow providers to benefit from more efficient workflows.
Details
During a roundtable involving industry leaders, major health insurers committed to improving the prior authorization process. These commitments cover plans such as Medicare Advantage and Medicaid, affecting nearly eight out of ten Americans. Key initiatives include the 'Standardizing Electronic Prior Authorization,' which involves developing common, transparent data submission requirements using FHIR® APIs. This new framework is targeted for operational use by January 1, 2027. Other commitments focus on reducing the scope of claims subject to prior authorization, ensuring continuity of care when patients change plans (for a 90-day transition period starting Jan 1, 2026), and enhancing transparency in determination decisions. Furthermore, insurers aim for at least 80% of electronic prior authorization approvals to be answered in real-time by 2027, requiring widespread adoption of FHIR APIs. These changes are designed to reduce administrative burdens on providers and improve the patient experience by ensuring seamless access to care. This initiative highlights a significant push toward standardization and digital transformation within the U.S. healthcare IT landscape.
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