Nearly 50 major insurers have announced a sweeping set of voluntary commitments aimed at simplifying prior authorization processes across commercial, Medicare Advantage and Medicaid managed care plans, potentially affecting 257 million Americans.
Here’s what ASCs need to know:
1. Participating insurers are working toward a standardized electronic prior authorization system with a target of 80% of approvals provided in real time by January 1, 2027.
2. Each health plan will identify specific reductions to prior authorization requirements, with implementation beginning January 1, 2026.
3. Beginning in 2026, if a patient switches insurance mid-treatment, the new insurer will honor existing prior authorizations for equivalent in-network services for 90 days.
4. By 2026, insurers will be required to clearly explain prior authorization denials, offer guidance for appeals and outline next steps. This will apply across fully insured and commercial plans.
5. A recent survey from the American Medical Association found that physicians and staff spend 13 hours per week on prior auth tasks. Nearly 40% of practices have staff exclusively dedicated to it, and burnout remains high.
6. Prior authorization rates are also increasing at ASCs. According to HST Pathways’ latest “State of the Industry Report,” 46% of cases completed preauthorizations in 2024, up from 42% in 2023.
6. A new CMS rule finalized in early 2024 mandating that certain payers will be required to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours for urgent requests and seven calendar days for standard requests.
7. AMA President Bobby Mukkamala, MD welcomed the progress but warned that “patients and physicians will need specifics” to ensure these promises translate into action.
8. ASC leaders have long criticized prior authorization for creating delays and frustration.
Andrew Lovewell, CEO of Columbia (Mo.) Orthopaedic Group, described a “cyclical” pattern of denials and “burdensome” peer-to-peer reviews.
“It’s becoming such a joke that we’re having to deal with all of these hoops to jump through just to take care of patients,” he told Becker’s.
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