HHS Pitches Prior Authorization Reform as Way to Improve Patient Experience for Millions

Millions of Americans will benefit from the Trump administration’s plans for prior authorization reform, according to Centers for Medicare & Medicaid Services administrator Dr. Mehmet Oz.

Oz and Health Secretary Robert F. Kennedy announced that major insurers have promised to ease “prior authorization” by creating a common standard for submitting electronic requests by the start of 2027.

Oz said insurance companies agreed “to sheath their swords, to be meek for a while, to come up with a better solution to a problem that plagues us all.”

Insurers fully or partially denied 3.2 million prior authorization requests in 2023, according to the American Medical Association.

But President Donald Trump’s Health and Human Services Department is improving timely access for patients, Oz said.

“This is a critical issue because imagine you’re at a doctor’s office and you’ve got a bad diagnosis, and there’s a procedure or a test or a treatment that you think is right for you, and you find out that you can’t start that treatment for sometimes weeks, a little bit longer,” Oz said.

“Patients should not be waiting because bureaucratic hurdles are blocking their critical treatment,” he continued.

HHS is also reforming the efficiency and transparency of the prior authorization program.

“Transparency comes with accountability,” Oz said. “If you now know what’s going on, you now have the responsibility of dealing with it. We have common data standards. They’re going to be adopted, and public dashboards are going to reveal to you and to patients what’s going on. So we’ll be able to audit if this is really happening.”

Centers for Medicare & Medicaid Services is going to publish a full list of plans participating in the reforms later this summer, as well as some details of how the reforms will work.

“CMS is engaging with providers to find out how they can refine documentation procedures, because that’s often where the entire process gets stuck. The records never get out of the doctor’s office in a timely fashion,” Oz said.

Chris Klomp, director of the Center for Medicare, said several procedures shouldn’t require prior authorization at all, like colonoscopies, cataract surgery, and vaginal delivery.

“I think the bigger point, and what we’re more focused on, is the process and the principles by which appropriate care is determined,” Klomp said.

Rep. Greg Murphy, a Republican doctor from North Carolina, said artificial intelligence should speed up the process.

“Artificial intelligence should help this tremendously, tremendously, and it should take out a lot of the variances that happen between doctors, hospitals, regions of the country, etc.,” Murphy said.

While previous administrations have made an effort to reform prior authorization, Oz believes this time will be different.

“There’s violence in the streets over these issues,” he said, alluding to the murder of UnitedHealthcare CEO Brian Thompson. “This is not something that is a passively accepted reality anymore. Americans are upset about it.”

“Secretary Kennedy made it very clear from the outset that we’re going to deal with this issue one way or the other,” Oz said. “We have legislation pending that would come in as well to codify some of these changes.”

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