Robert Kennedy, Mehmet Oz Announce and Insurance Providers Co-Sign Pre-Authorization Process Changes

Thanks to dropping of A-bombs and F-bombs over the Iran/Israel War and the tenuous ceasefire, this news slipped under the radar. While not as edge-of-your-seat as talk of World War III, this is a huge policy shift that will greatly impact American lives.

On Monday, Health and Human Services (HHS) Secretary Robert Kennedy, and Dr. Mehmet Oz, Administrator for Centers for Medicare & Medicaid Services (CMS) had a press conference where they pledged to streamline the authorization processes for Medicare, Medicaid, the Health Insurance Marketplace, and commercial plans that in which a majority of Americans participate.

The HHS website press release announced,

U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz today met with industry leaders to discuss their pledge, links to an external website, opens in a new tab to streamline and improve the prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace® and commercial plans covering nearly eight out of 10 Americans.

In a roundtable discussion hosted by HHS, health insurers pledged six key reforms aimed at cutting red tape, accelerating care decisions, and enhancing transparency for patients and providers. Their commitments reinforce the role of CMS in monitoring outcomes and promoting accountability. Companies represented at the roundtable included Aetna, Inc., AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Inc., Kaiser Permanente, and UnitedHealthcare.

Basically, every major health insurer in the United States. This matters. 

“Thank you to the insurance companies for making these commitments today. Americans shouldn’t have to negotiate with their insurer to get the care they need,” said Secretary Kennedy. “Pitting patients and their doctors against massive companies was not good for anyone. We are actively working with industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy, and outpatient surgery.”

For those who have never had the unfortunate experience of needing a pre-authorization or physician referral for a screening procedure or further diagnosis, you are most blessed. A relative was hospitalized for a serious, but thankfully not catastrophic, condition. He was released after seven days, which was the max his insurance provider would pay for. Because he had to see his primary care physician before he could see a specialist, he had to wait another week post-hospitalization. He finally saw his PCP and received their referral for a specialist, but with approvals, it was another two weeks before he could get in to see that specialist. Now multiply that by several conditions, several practitioners, and even longer wait times, and you have untold stress and exacerbated health conditions due to this round-robin insurance game. 

“These commitments represent a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care,” said Administrator Oz. “We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first.”

• 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.

Despite making noises in the past to reform the system, the major providers appear more invested in the overhaul process this time around. One reason could well be that it has become a matter of life and death for them. The December 2024 murder of UnitedHealthcare CEO Brian Thompson in New York was purportedly because the alleged killer, Luigi Mangione, was denied a procedure that would have improved his quality of life. With 40 percent of Gen Z supporting Mangione, saying that his actions were justified under the circumstances, the insurance provider CEOs are making very public moves to ensure Americans see their commitment to change, and that they will do what is within their power to see it done.