Health insurance companies to change previous approvals
HHS Secretaries Robert F. Kennedy and Dr. Mehmet Oz announced that major insurers have agreed to reduce and streamline their prior approvals
Large health insurance companies have vowed to reduce the use of and improve common tools for reviewing requests before they can request medical services or prescriptions from their doctors.
UnitedHealthcare, Blue Cross Blue Shield, Cigna, Kaiser Permanente, Humana and other health insurance companies announced plans on June 23 to “rationalize, simplify and reduce previous approvals.” Doctors and patients say they report investigations and government oversights that practices routinely delay or deny care.
The changes to previous approvals will be gradually progressive over the next year and a half, the company said. Overall, the insurance company said the change would apply to 257 million Americans covered by private commercial insurance, Medicare Advantage and Medicaid Management Care Plans.
Health and Human Services Secretary Robert F. Kennedy Jr. and Mehmet Oz, manager of the Centers for Medicare and Medicaid Services, praised insurance reforms at a press conference on Monday in Washington, D.C.
Oz and Kennedy noted that insurers are voluntarily making these changes, but Oz said that if the insurers are not making improvements to their commitments, the federal government can enforce the changes to adopt rules and regulations.
“I’m optimistic and I hope there’s no need to do that, but it’s always included in my back pocket whenever I need it,” Oz said.
What is pre-approval?
With prior permission, the doctor or hospital must contact the patient’s health insurance company prior to care for certain prescription medications such as surgery or prescription. Doctors complain that this process is burdensome and are often used to delay or reject medical care that patients need medically. Insurance companies argue that approval is an important tool to prevent unnecessary testing and medical care that inflates medical costs for families.
During a confirmation hearing in March, Oz said advance approvals were “in some cases misused” by private Medicare plans and need to be addressed. He proposed a list of services with clear explanations that allow private Medicare plans to use pre-approval.
One in five adults with health insurance said they had experienced previous permitting issues over the past year, according to a 2023 survey by KFF, a health policy nonprofit.
Oz said that private insurers that Medicare Advantage partially or entirely rejected 3.2 million pre-approval claims in 2023.
Insurance companies pledge timely decisions
The changes that insurance companies have pledged will result in faster patient access and bring fewer challenges, according to a statement shared by trade group U.S. Health Insurance Plans.
The group said health insurance companies will “reduce the scope of claims” that will be subject to prior approval. The insurance company also said measures will be implemented to ensure continuity of care when patients switch plans and provide a clearer explanation of their decisions.
Large insurers try to standardize their computer systems to handle pre-approval requests. The idea is to “put patients into paperwork,” allowing insurance companies, doctors and hospitals to exchange digital information in a standard way, Oz said.
In a statement, Ahip President and CEO Mike Tuffin said the health plan “has a voluntary commitment to deliver a more seamless patient experience,” allowing physicians to focus on patient care.
Will insurance companies really step up? ”
This is not the first time the federal government has called attention to approval of health insurance for medical care.
In 2018, during President Donald Trump’s first term, large insurers and major healthcare groups agreed to terms on how advance approvals should be handled. However, the effort did not make much progress.
Oz admitted that past efforts did not result in any meaningful changes to prior approval. But he said the public is demanding change.
“There’s violence on the streets against these issues,” said Oz, a reference to the December 2024 assassination of United Care CEO Brian Thompson.
“This isn’t a passively accepted reality, and Americans are upset about it,” Oz added.
Rep. Greg Murphy, a North Carolina Republican and doctor, said he often has to comfort crying patients whose care has been denied by insurance companies.
However, he also said doctors must share “some criticism” about habits such as ordering unnecessary tests.
He is pleased that the insurance company has agreed to deal with advance permissions. But he said there is evidence to how these companies continue.
“As a surgeon, I’m skeptical,” Murphy said. “Are they really going to step up and do things, or are they doing something to appease the audience?”
(This story has been updated to add new information.)
