On Monday, a cohort of about 50 health insurance plans — including UnitedHealthcare, SCAN Health Plan, Kaiser Permanente, Humana and more — announced a government-sponsored pledge to reduce prior authorizations.

Home-based care industry advocates applauded the move to reduce prior authorizations and shorten turnaround times, but noted that the pledge fell short of adequately addressing prior authorizations in post-acute care settings, including home health.

“We hope these efforts will extend meaningfully to post-acute care settings — particularly skilled nursing facilities (SNFs) and home health agencies — where delays and denials are most frequent and often most harmful,” Nicole Fallon, vice president of integrated services and managed care policy at LeadingAge, told Home Health Care News in an email. “Patients leaving the hospital for post-acute care face some of the highest rates of denied or delayed authorizations. So far, the announcements from insurers have not addressed prior authorization practices in these settings, nor have they acknowledged the burden of ongoing concurrent review requirements.” 

Washington, D.C.-based LeadingAge is an association of more than 5,000 nonprofit aging services providers and organizations.

Fallon also stated that many of the promised improvements align with existing regulatory requirements or those already planned for implementation.

The National Alliance for Care at Home  (the Alliance)  lauded the health insurance plans’ commitment to reform prior authorization practices.

“If these promises are fully kept, this could be a meaningful step toward addressing longstanding barriers that have delayed access to critical care at home for patients who need it,” Dr. Steve Landers, CEO of the Alliance, said in a statement. “Our members who provide essential care welcome initiatives that potentially reduce administrative burden and improve communication with insurers, freeing up scarce clinical capacity and resources for direct patient care rather than navigating red tape.”

The Alliance is an advocacy organization representing providers of home care, home health, hospice services, palliative care and other health care services.

In a press conference held by the U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz, Oz specified that the agreement was not a mandate.

“This is not a bill or rule,” he said. “This is not legislated. This is an opportunity for [the] industry to show itself. Participation is voluntary, but by the fact that three-quarters of the patients in the country are already covered by participants in this pledge, it’s a good start. The response has been overwhelming, gratifyingly so. The effort took place with the government as a sponsor, as a steward, as a cheerleader.”

Broadly, prior authorization requires providers to receive the go-ahead from health plans before delivering care services or prescribing prescription drugs, in terms of coverage.

The health insurance companies that joined in the pledge said that the move would create greater access to care for patients and a more efficient process for providers.

“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” Mike Tuffin, president and CEO of America’s Health Insurance Plans (AHIP), said in a press statement. “Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system.”

AHIP is a Washington, D.C.–based national trade association that represents the health insurance industry.

Some of the key steps health insurers committed to are standardizing electronic prior authorization, reducing the scope of claims subject to prior authorization and ensuring continuity of care when patient plan changes occur.

Additionally, health insurance plans are committed to enhancing communication and transparency on determinations, expanding real-time responses and ensuring medical review of non-approved requests.

“These measurable commitments – addressing improvements like timeliness, scope and streamlining – mark a meaningful step forward in our work together to create a better system of health,” Kim Keck, president and CEO of Blue Cross Blue Shield Association, said in the statement. “This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience.”

On its end, Better Medicare Alliance believes that the health insurers’ announcement is a step in the right direction.

“Prior authorization helps keep costs down and ensures patients get the best care, but it should be easier,” Mary Beth Donahue, president and CEO of Better Medicare Alliance, said in a statement. “These commitments will make a positive difference — reducing unnecessary delays and denials for millions of Americans, including seniors enrolled in Medicare Advantage. We applaud this step and remain committed to engaging policymakers around this important issue.”

Oz also noted that the pledge was the first step in a larger modernization push.

“It’s not just about prior authorization,” he said. “It’s a template for administrative simplification to take the paperwork out of the process and put patients over paperwork. There is going to be a single FHIR-based electronic workflow. FHIR is a Fast Healthcare Interoperability Resources, so it’s a standardized way for information exchange across systems. We’ll have real-time decision-making for most electronic requests by 2027. We’re going to have to work with providers, with doctors, many of whom, maybe half potentially, aren’t using these kinds of technologies routinely in their office practice when they interact with insurers. We want that to change.”