AHIP (formerly America’s Health Insurance Plans) released a statement yesterday saying that their health plan members “announced a series of commitments to streamline, simplify and reduce prior authorization.” 48 US health plans signed off on the statement. What were AHIP’s 6 commitments?
Standardizing Electronic Prior Authorization. Participating health plans will work toward implementing common, transparent submissions for electronic prior authorization. This commitment includes the development of standardized data and submission requirements (using FHIR® APIs) that will support seamless, streamlined processes and faster turn-around times. The goal is for the new framework to be operational and available to plans and providers by January 1, 2027.Reducing the Scope of Claims Subject to Prior Authorization. Individual plans will commit to specific reductions to medical prior authorization as appropriate for the local market each plan serves, with demonstrated reductions by January 1, 2026.Ensuring Continuity of Care When Patients Change Plans. Beginning January 1, 2026, when a patient changes insurance companies during a course of treatment, the new plan will honor existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions.Enhancing Communication and Transparency on Determinations. Health plans will provide clear, easy-to-understand explanations of prior authorization determinations, including support for appeals and guidance on next steps. These changes will be operational for fully insured and commercial coverage by January 1, 2026, with a focus on supporting regulatory changes for expansion to additional coverage types.Expanding Real-Time Responses. In 2027, at least 80 percent of electronic prior authorization approvals (with all needed clinical documentation) will be answered in real-time. This commitment includes adoption of FHIR® APIs across all markets to further accelerate real-time responses.Ensuring Medical Review of Non-Approved Requests. Participating health plans affirm that all non-approved requests based on clinical reasons will continue to be reviewed by medical professionals – a standard already in place. This commitment is in effect now.
This leads to a number of questions:
Why is AHIP doing this? A number of states have begun to legislate restrictions around prior authorization (see here, here). Additionally, there was pressure from the federal level as well (see HHS announcement on Monday). Perhaps AHIP members prefer to address prior authorization issues proactively, rather than be legislated into change. How fast is real-time? AHIP is committing to >80% of prior authorizations will be “real time”. How fast is ‘real time’? If the answer is instantaneously, then there would need to be a software-based (AI?) solution for answering these PA. If this is not software based, then “real time” could be slower than anticipated. Easy to understand for whom? AHIP is committing to creating transparent, easy to understand guidelines. A key question is, for whom will they be easy to understand? If it is patients, these guidelines could be very simplified and could be less useful for physicians to understand. If AHIP makes the documents easy to understand for physicians, detailed clinical language would be needed, which would make the documents less easy to understand for patients. Alternatively, AHIP could have two sets of documents: one for patients and one for physicians. Continuity of care is good, right? YesHow large will the prior authorization scope reduction be? This is still to be determined.
Is this a major change in how prior authorizations are run or will this result in few material changes to the prior authorization process? Let me know your thoughts.
