On Monday, June 23rd,  Department of Health and Human Services (HHS) Secretary Kennedy and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz announced that they have secured a pledge from the insurance industry to improve prior authorization processes. Participating insurers promise to standardize electronic using FHIR APIs, reduce the volume of services subject to prior authorization by the end of the year, ensure continuity of care, enhance transparency, expand real-time responses and ensure medical professionals review clinical details. Insurers participating in the Pledge include Aetna, Blue Cross Blue Shield, Centene, Cigna, Elevance, GuideWell, Highmark Health, Humana, Kaiser and UnitedHealthcare.  

Key Points: 

  • No new CMS policy was announced.  
  • Dr. Oz and Secretary Kennedy acknowledged that prior authorization is becoming a significant issue impacting patients and shared some patient stories. They also recognized that prior authorization is wasting time and resources from both patients and providers, increasing costs.   
  • Dr. Oz acknowledged previous industry pledges to change. Two things have changed, he said. “I mean, there’s violence in the streets over these issues,” Dr. Oz said. He was alluding to the shooting of UnitedHealthcare CEO Brian Thompson in New York in December 2024. 
  • Despite the acknowledgement, there was no explicit commitment from CMS to improve prior authorization. It was more of a “If you don’t fix this, we will” type of message.  
  • Dr. Oz reiterated that the issue of prior authorization is necessary to control costs but that insurance companies should narrow down the scope of prior-authorization to address the services most likely to be abused. 

Summary: 

  • Highlighted patient delays and provider burdens caused by current system. 
  • Advocated for federal legislation and real-time electronic authorization systems. 
  • Participating health insurers have pledged to: 
  • Standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces. 
  • Reduce the volume of medical services subject to prior authorization by Jan. 1, 2026. 
  • Honor existing authorizations during insurance transitions to ensure continuity of care. 
  • Enhance transparency and communication around authorization decisions and appeals. 
  • Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027. 
  • Ensure medical professionals review all clinical denials. 
  • CMS will post the insurance companies that make the pledge later on their website.  

Key Quotes: 

“The most important reality is, the administration has made it clear we’re not going to tolerate it anymore, so either you fix it, or we’re going to fix it. And I think they wisely have decided they should fix it. I’m looking forward to seeing the results,” Dr. Oz said. 

“It frustrates doctors. It’s sometimes results in care that is significantly delayed. It erodes public trust in the health care system. It’s something we can’t tolerate,” Dr. Oz said. 

“The proof is going to be in the pudding. Are they really going to step up and do things, or are they doing something to placate an audience?,” Rep. Greg Murphy, MD (R-NC) said.  

“For nearly my entire time in Congress, I fought to reform the prior authorization process in Medicare Advantage,” Marshall said. “Today’s event moves us closer to that goal, ensuring patients receive timely, life-saving, and health restoring care,” Senator Marshall (R-KS) said.