After years of frustration, prior authorization reform is finally gaining real attention. And not just in healthcare circles. This week, major insurers and health systems signed a federal pledge to reform a process that has been hindering patient care for decades.
According to the Department of Health and Human Services and supported by voices like RFK Jr., Dr. Oz, and Senator Chris Murphy, the pledge outlines several key promises:
- 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 January 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.
It all sounds good. But if you’ve ever waited days for an MRI approval or a time-sensitive medication refill, you know this change is overdue. Prior authorization isn’t just an administrative headache. It’s often a real barrier to care. In a recent AMA survey, 93% of physicians said it delays treatment. One in four said it has caused serious harm to patients.
For employers, this isn’t just a healthcare problem—it’s a business one. When employees can’t access timely care, they stay sick longer, miss more work, and increase long-term healthcare costs. It also hurts morale. No one should have to fight their insurer while dealing with pain or a diagnosis.
While the pledge is voluntary, there’s real momentum behind it. CMS has already finalized rules that require electronic prior authorization for Medicare Advantage and Medicaid by 2027. Private insurers are now trying to prove they can self-regulate before stricter mandates arrive.
At SolV, we’re cautiously optimistic. Reforming prior authorization could finally remove one of the most frustrating obstacles in healthcare—for patients, providers, and HR teams alike. But words aren’t enough. Real change takes follow-through.
We’ll keep watching—and advising our clients on how to prepare for whatever comes next.
Bottom line: Whether reform happens or not, your health plan needs to work in the real world. We can help make sure it does.