A year ago, the fatal shooting of a health insurance executive on a Manhattan sidewalk unleashed many Americans’ pent-up frustration with insurers’ delays and denials of care.
UnitedHealthcare CEO Brian Thompson’s shooting shone a spotlight on the longstanding and controversial practice of prior authorization, which requires insurers to approve care in advance. They say prior authorization is needed to help ensure that doctors provide safe, appropriate and affordable care. But providers and patients counter that such requirements are overly burdensome and slow critical testing and treatment.
Luigi Mangione, who vented his anger with the health insurance industry in diary entries before Thompson’s death, is facing charges in state and federal courts. Mangione, who has pleaded not guilty, appeared in a Manhattan court this week as his attorneys seek to have his diary entries and other evidence tossed from his state murder case.
Thompson’s killing and the resulting public outcry led insurers and their industry associations to pledge to simplify and streamline prior authorization practices. Top Trump administration health officials held a news conference in June to announce the voluntary multipart plan, which includes three measures set to kick in January 1. They include reducing the number of claims that require preapproval and improving communication with patients.
However, multiple provider associations and patient advocacy groups interviewed by CNN say that little, if anything, has changed over the past year.
“From where we sit, we’ve seen no change in the burdens both providers and beneficiaries must go through to get medically necessary care,” said David Lipschutz, co-director of the Center for Medicare Advocacy.
Navigating the prior authorization process has long been a major health care headache for Americans. It’s hard to get reliable data on delays and denials for those who have coverage through their jobs, but inappropriate denials by Medicare Advantage insurers have come under fire in recent years from the US Department of Health and Human Services and some lawmakers.
Half of insured adults say they or their provider have had to obtain prior authorization before they could get a health care service, treatment or medication in the past two years, according to a KFF survey published in July. Of those, nearly half said it was “very difficult” or “somewhat difficult” to navigate the process.
“Prior authorization has created a real administrative burden for consumers and providers in trying to access care they thought was covered by their insurance,” said Kaye Pestaina, director of KFF’s Program on Patient and Consumer Protection.
Some insurers have sought to simplify their prior authorization requirements in recent years. But in June, dozens of health insurers covering 257 million people committed to six steps to make it easier for patients to get appropriate care, according to a news release from the industry’s two major trade groups, the Blue Cross Blue Shield Association and AHIP, formerly known as America’s Health Insurance Plans. The measures apply to those with commercial, Medicare Advantage and Medicaid managed care coverage.
“For patients, these commitments will result in faster, more direct access to appropriate treatments and medical services with fewer challenges navigating the health system,” the release said. “For providers, these commitments will streamline prior authorization workflows, allowing for a more efficient and transparent process overall, while ensuring evidence-based care for their patients.”
The insurers have agreed to reduce the scope of claims subject to preapproval by the start of 2026, as well as to ensure that plans honor existing prior authorizations for 90 days for patients who change carriers during treatment.
Insurers say they will provide clear explanations of their determinations, including information about appeals. These changes will be in place for those with commercial coverage by January, and the industry will work with regulators to expand this step to other coverage types.
More changes are set to take place in 2027. The participating health insurers have promised to work toward a common electronic prior authorization process, which they say will help speed the decision timeline.
Also, carriers will expand the share of electronic prior authorization approvals answered in real time to at least 80% in 2027, if all needed clinical documentation is submitted. And all requests that are denied will continue to be reviewed by medical professionals, which is the current standard.
Many of the nation’s largest insurance carriers have signed on to the commitment, including UnitedHealthcare, CVS Health’s Aetna, Cigna, Humana, Elevance Health (formerly Anthem), Kaiser Permanente and dozens of Blue Cross Blue Shield plans.
Asked what steps insurers have taken since the announcement, the Blue Cross Blue Shield Association said, “We’re making meaningful progress on improving the prior authorization process.”
“As outlined in our recent announcement, with many improvements going live in January, we remain committed to streamlining processes and reducing the scope of requirements to improve the experience for patients and providers,” the association said in a statement. “We look forward to sharing our progress in the spring.”
This year, Cigna eliminated prior authorization mandates for nearly 100 medical services and introduced new ways to check the status of requests in real time, a spokesperson said in a statement. Also, it added to its team of advocates who assist patients, including with prior authorizations.
Several other insurers contacted this week pointed to prior announcements but declined to provide details on their progress in instituting the reforms.
One carrier referred a reporter to AHIP, which told CNN, “Throughout this ongoing multi-year effort, progress will be tracked and reported publicly. We anticipate the first report will come in the spring of 2026.”
Humana is on track to meet the commitments it outlined in a July news release, according to spokesperson Kevin Smith. They include eliminating about one-third of prior authorizations for outpatient services, such as colonoscopies and certain CT scans and MRIs, and providing a decision within one business day on at least 95% of all complete electronic prior authorization requests by January 1, according to the news release.
In October, Humana CEO Jim Rechtin told CNN that prior authorization is an important tool to make sure policyholders are getting the right care.
“Prior auth, when done effectively, is a check and balance on the system to make sure that that’s what they’re getting,” he said, adding that the company is accelerating its effort to provide automated responses – which are approvals most of the time – to the vast majority of requests.
UnitedHealthcare said it remains committed to achieving each of the provisions in the June announcement. Over the past few years, it has been reducing the number of prior authorizations required for services that consistently adhere to evidence-based guidelines and are typically approved.
Asked about its progress, Aetna referred to a June news release that said it would simplify the prior authorization process by bundling multiple requests for MRIs or CT scans for patients with lung, breast or prostate cancer into one request. On Thursday, the insurer announced that it is bundling prior authorization requests for musculoskeletal conditions that include X-rays, knee arthroplasty surgical procedures, certain medications and other care. Also, it is integrating prior authorization requests for medical procedures and pharmacy prescriptions so only one authorization is needed.
Dr. Mehmet Oz, administrator of the US Centers for Medicare and Medicaid Services, said at a Medicare Advantage forum in October that prior authorization is needed but has to be done the right way. Increasing the speed of decisions and eliminating delays due to paperwork issues are important steps.
“It is quite effective, as you all know, in addressing wrongful procedures and inappropriate expenses, but it has been used at times in ways that are very confusing for the American public and maddening,” he told attendees at the Better Medicare Alliance forum.
The US Department of Health and Human Services “is engaged in ongoing conversations with industry to ensure their continued commitment to the industry pledge made in June,” a CMS spokesperson said.
Insurers’ adherence to the commitments will be posted on a dashboard that will allow the agency, patients, providers and others to assess the industry’s progress, Oz said in June.
Although the insurers’ commitments in June were voluntary, they will be required to make decisions on urgent prior authorization requests within 72 hours and on standard requests within seven days, as well as to report certain metrics about their prior authorization processes and send doctors specific reasons for denials in Medicare Advantage and Medicaid programs starting in January under rules approved by the Biden administration.
Health care providers generally say they have yet to see much, if any, improvement in the prior authorization process.
Dr. Bobby Mukkamala, an ear, nose and throat specialist in Flint, Michigan, said insurers have not lifted any prior approval requirements for his practice or for his wife’s obstetrician-gynecologist practice. Approvals can take several hours or more than a week if the request was denied. But his staff reports that now there may be a few requests that no longer require a phone call as part of the process.
“Everything that used to require prior authorization still does,” said Mukkamala, who is president of the American Medical Association, a fierce critic of the practice.
Also, he has not heard of any notable improvements in the preapproval process from members.
Similarly, American Hospital Association members haven’t seen much movement this year, said Terrence Cunningham, senior director of administrative simplification policy.
The association would like insurers to ease prior authorization requirements in areas that often entail a lot of documentation or discussion, such as transferring patients to rehabilitation or skilled nursing facilities after hospitalizations.
“[In] the areas where our providers are reporting the largest kind of administrative burden, we have not seen much of a rollback of those procedures or a change in how plans are approaching those processes,” he said, adding that building systems that would allow insurers to extract the necessary information directly from a patient’s electronic health record to satisfy a prior authorization request would be a game changer.
Some family medicine doctors, however, are seeing some easing in the process, said Shawn Martin, CEO of the American Academy of Family Physicians. For instance, insurers are using technology to speed up decisions on prior authorization requests.
“I do think they got the message that there was frustration among all parties, but they still have a lot of work to do,” Martin said of insurers.
Advocates who help people navigate the health care system also say they haven’t noticed much progress this year.
While insurers are looking at the issue in the right way, their efforts should not be voluntary since they could just opt out at any time, said Caitlin Donovan, senior director of the Patient Advocate Foundation, which provides case management and financial assistance. Instead, the reforms should be based on regulations.
Aija Nemer-Aanerud, health care senior strategist at the People’s Action Institute, was even more doubtful, noting that prior authorization improves insurers’ finances.
“It’s all tinkering around the edges,” Nemer-Aanerud said. “I’m skeptical about things changing in any major way.”