Payers made bold prior authorization commitments in 2025. Here’s what to expect through 2026

Prior authorization has long been a sticking point between payers, who believe it is necessary to control costs and ensure care is medically necessary, and providers, who believe it creates administrative burdens and delays care.

Regardless of who is right in this debate, it is clear that the practice desperately needs improvement. That’s why in June, more than 50 health plans — such as UnitedHealthcare, Aetna, Cigna and several Blues plans — partnered with the Centers for Medicare and Medicaid Services to make a series of commitments to streamline prior authorizations, including providing clearer explanations of prior authorization decisions, increasing turnaround times for decisions and ensuring continuity of care when patients switch plans. Some of these commitments will be fulfilled in 2026, and others will come into effect in 2027.

“We are making meaningful progress on improving the prior authorization process… With many improvements set to be implemented in January, we remain committed to streamlining the process and narrowing the requirements to improve the patient and provider experience,” a Blue Cross Blue Shield representative told MedCity News on condition of anonymity.

Still, the question remains whether these promises will be enough for providers, who are often cautiously optimistic about them.

“Any reduction in prior authorizations, the relief that family physicians have been asking for for years, is welcome,” said Dr. Jen Brull, president of the American Academy of Family Physicians' Board of Directors. “From our perspective in the exam room, promises alone are not enough. Prior authorizations still take up a lot of time and cause real delays in care; nearly 90 percent of physicians say it is extremely burdensome. Until we see meaningful changes that truly reduce paperwork and speed up approvals, patients and physicians will continue to feel the pinch.”

In addition to these commitments, there are additional advances in the prior authorization area through 2025, including the introduction of the WISeR model, which extends prior authorization requirements to traditional Medicare. In 2026, experts will also be watching progress on the Improving Timely Access to Care for Seniors Act, which would streamline prior authorization for Medicare Advantage.

What are the commitments for 2026?

According to AHIP’s June announcement, the commitments effective in 2026 are:

• Reducing the scope of claims requiring prior authorization: Insurers will reduce prior authorization requirements for certain claims, which will depend on the markets served by each plan. These reductions are expected to begin on January 1, 2026.
• Ensuring continuity of care when patients switch plans: When patients switch insurance plans during treatment, their new insurance company must honor existing prior authorizations for similar in-network services within 90 days to ensure continuity of care and prevent delays. This will begin on January 1, 2026.
• Improve communication and transparency of decisions: Insurers are committed to providing clear explanations of prior authorization decisions, as well as appeals information. By January 1, 2026, this will apply to both full and commercial insurance.

In 2027, payers will focus on standardizing electronic prior authorization and scaling up real-time responses. Insurers expect at least 80% of electronic prior authorization approvals to be responded to in real time.

A total of 53 plans signed all of these pledges, including the biggest names in health insurance: UnitedHealthcare, Elevance Health, Aetna, Cigna, Kaiser Permanente, Centene, Humana, Highmark and multiple Blues plans.

AHIP spokesman Chris Bond told MedCity News that progress will be tracked and reported publicly. The organization expects the first report to be released in spring 2026.

Some payers told MedCity News they are on track to meet their 2026 commitments. 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 preparation, including hosting an October summit to review commitments and holding one-on-one meetings with various groups to help them understand and prepare for the changes.

Still, there are challenges in delivering on these commitments in sequence. For example, meeting the promise of electronic prior authorization by 2027 will require significant efforts to support providers who currently lack the technical infrastructure and resources required to submit prior authorization requests electronically.

“Some of these technologies are very expensive, especially for smaller groups,” Hammash said. “That's one of the challenges that we have to look at and see what is the best way for us to work with these providers to solve these problems because we have to move away from traditional paperwork and faxing to using technology that helps us speed up the process.”

An executive at Blue Shield of California also said more advanced technology is needed to ensure these promises are effective.

“Health plans need to leverage internal intelligence about members, policies, benefits and networks to facilitate automated approvals at scale,” said Dr. Laurine Tibaldi, vice president of medical management at Blue Shield of California. “We want to see more providers using technology as much as possible to communicate with health plans to replace faxes or phone calls. More real-time communication between health plans and providers will help patients get care faster and reduce stress for everyone involved.”

Aetna President Steve Nelson told MedCity News the insurance company is working hard to meet those commitments and aim for higher goals. For example, it announced in December that it would bundle medical procedures and medications into one prior authorization. Previously, healthcare providers had to submit two separate prior authorizations for medical procedures and related medications. In addition, the insurance company is working to increase transparency in the process.

“One of the frustrating things about prior authorization is you don’t know where you are in the process,” Nelson said in an interview. “We've added functionality to the digital app so you now know where you are in the process. Is it pending? Has it been rejected? What's the next step? Has it been approved? How's it going?”

Is this enough for providers?

While doctors are generally optimistic about these promises, it goes without saying that there is also some skepticism.

To hold payers accountable, Brewer said providers should make sure to document delays, denials and inconsistencies and bring those concerns to lawmakers.

Lynn Nonnemaker, a health insurance policy expert at consulting firm McDermott+, said skepticism among health care providers is “appropriate and healthy” and will play a role in ensuring plans are implemented. She added that CMS Administrator Dr. Mehmet Oz has said the agency is prepared to take action if the plan fails to materialize.

“Of course, CMS could further restrict plans’ use of prior authorization,” she said in an interview. “One important thing CMS can do is serve as a convener and help bring greater standardization to the systems and processes that programs use and the way providers interact with them.”

Nonnemaker's colleagues note that while insurers have a responsibility to fulfill these commitments, providers can also take their own steps to improve prior authorization.

“It takes two to tango,” said Jeffrey Davis, director of McDermott+. “So if payers want to automate the process, that means the provider side has to have the technology and systems in place to handle these automated transactions. Providers have to accept that as well and build their systems. Payers can do whatever they want, but if providers aren't involved, there won't be a seamless prior authorization process.”

An executive at GuideHealth, a technology-based value care delivery company, agreed.

“Healthcare providers can improve outcomes by standardizing submissions, using structured clinical data and working with payers to follow an evidence-based pathway,” GuideHealth founder and CEO Sanjay Doddamani said in an email. “Thinking of prior authorizations as a shared clinical and operational workflow, rather than a downstream administrative task, is key to reducing friction.”

In addition to these commitments, Brewer also hopes to see progress on the Seniors' Timely Access to Care Act, which would streamline prior authorization for Medicare Advantage.

“The House has passed it once and we're working hard to get across the finish line,” she said. “Ultimately, prior authorization should never be a barrier between patients and timely care, and physicians should be able to focus on caring for patients, not paperwork.”

It's a burden that most doctors feel, with 94% of physicians surveyed by the American Medical Association saying prior authorizations lead to significant delays in necessary care. There are also economic reasons for reducing prior authorization. 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.

Brewer is also concerned that some of the moves CMS is taking could have worrisome impacts, given the burden of prior authorization. She said new innovative models may “reintroduce prior authorization under a different name or mechanism, meaning practices must remain vigilant to keep patient care flowing smoothly.”

For example, in June, the CMS Innovation Center launched the WISeR model (Waste and Inappropriate Services Reduction Model), which brings the prior authorization process to traditional Medicare to reduce “fraud, waste, and abuse.” That worries Brewer because traditional Medicare “has not had these barriers for a long time.” That could slow down care for older adults and create more administrative challenges for practices, she said.

Photo: Piotrekswat, Getty Images