Highmark joins major insurers in prior authorization reform

Highmark was among more than 50 health insurers who pledged Monday to speed up and slim down prior authorization, the process through which patients and their doctors must seek insurance approval for certain care before it’s administered.

“It’s all about decreasing the administrative burden,” said Highmark Chief Medical Officer Tim Law. “My mantra in this industry is the health plan should be a conduit to care between the provider and the patient, not the roadblock that everyone thinks we are.”

Some of the country’s largest health insurers, including UnitedHealthcare, Elevance Health, Centene, CVS Health, Humana and Blue Cross Blue Shield, made the same commitments. According to Law, the companies first started discussing reforms in January or February.

UPMC Health Plan, with its more than 4 million members, was one of the only major industry players not on the list.

A UPMC spokesperson acknowledged the organization hasn’t joined the newly announced national agreement but remains open to collaborative solutions.

The cross-provider changes include reducing the number of claims subject to prior authorization, honoring approvals for 90 days if patients change companies during a course of treatment and providing clear, easy-to-understand explanations of prior authorization denials by the start of 2026, according to AHIP, a national trade group representing health insurers.

Participating companies also promised to create a standard electronic prior authorization form by the start of 2027. Along that same time frame, there are plans to make sure at least 80% of these requests (as long as they include all needed clinical documentation) are answered in real time. That effort will be aided by the adoption of software that allows health systems to exchange data.

The commitments will impact 257 million Americans on private health insurance as well as on Medicare and Medicaid.

Prior authorization explained

Prior authorization, also known as precertification, preauthorization or preapproval, most often applies to care that is complex or expensive, like inpatient surgeries or cutting-edge cancer drugs.

The industry argues the process limits fraud and protects patients from unnecessary care. As Law noted, prior authorization gives the heads-up insurance companies need to connect patients with case managers and other benefits.

It’s also a cost-control measure, even if insurance companies won’t lead with that.

The process typically starts with a doctor contacting the insurance company, though patients can do so on their own in some cases. From there, insurers vet the claims. These requests are usually run through automated software and approved or passed along to in-house health care professionals for further review.

Many doctors say prior authorization slows their ability to deliver care, fills their days with paperwork instead of patient visits and makes an already high-stress profession all the more challenging.

In a 2024 American Medical Association survey, 93% of physicians reported patients that sometimes, often or always encounter delayed access to needed care because of prior authorization. And 82% said the process at least sometimes drives patients to abandon recommended treatment.

Furthermore, 8% claimed a prior authorization delay has led to disability or death.

“This has always been a barrier to better care,” said Keith Kanel, president of the Allegheny County Medical Society. “The fact that it was delaying care for our patients was the thing that perhaps the most concerning for us.”

Offering more real-time answers could alleviate these issues. But according to Law, instant decisions will only be available when doctors submit their requests electronically rather than over the phone or fax machine.

He estimated 80% to 90% of doctors submit prior authorization requests to Highmark using an online portal, up from about 40% before the covid-19 pandemic.

Ultimately, Kanel would like to see prior authorization done away with altogether.

“We feel very strongly that we know how to use resources wisely,” said Kanel, who heads an association of more than 1,000 physicians. “It’s part of our training and it’s part of our custom.”

Legislative action

The industry’s action on prior authorization comes after years of scrutiny from not only doctors but also lawmakers.

In 2022, the Pennsylvania General Assembly passed a bill requiring insurers to publish treatments and drugs requiring prior authorization as well as the criteria used to approve or deny coverage. The law also sets deadlines for insurance companies to respond to requests, expands fast access to opioid use disorder treatments, allows patients to request exemptions from step-therapy programs and more.

Around 20 states have passed similar laws regulating prior authorization since.

At the federal level, several legislative attempts at reform have fallen short or stalled, ranging from narrow fixes for Medicare Advantage plans to bans on prior authorization in any form. New rules set by the Centers for Medicare and Medicaid Services, however, are set to go into effect next year in an effort to simplify and expedite the process.