Recently there were two major announcements from commercial and government payers about changes to how these insurers use prior authorization.
Reforming how health plans overutilize prior authorization is one of the Advocacy Council’s top advocacy priorities and will continue to be a top priority despite these announcements. Below is an overview of how these actions will impact allergy practices.
The first action is summarized in a press release from America’s Health Insurance Plans (AHIP), the largest national trade association for commercial health plans, in which 50 commercial health plans outlined new voluntary actions they will take to improve prior authorization for physicians and patients.
The participating health plans agree to:
- Implement standardized data and submission requirements (using FHIR® APIs). The goal is for the new framework to be operational and available to plans and providers by Jan. 1, 2027.
- Reduce claims subject to prior authorization by Jan. 1, 2026.
- Beginning Jan. 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.
- Provide clearer explanations of prior authorization determinations, including support for appeals and guidance on next steps by Jan. 1, 2026.
- Set a goal for at least 80% of electronic prior authorization approvals (with all needed clinical documentation) will be answered in real-time in 2027 by relying on adoption of FHIR® APIs across.
- Affirm that all nonapproved requests based on clinical reasons will continue to be reviewed by medical professionals – a standard already in place. This commitment is in effect now.
These commitments would achieve many of the reforms sought by the Advocacy Council. However, health plans have made similar promises in the past, yet prior authorization is as burdensome as it has ever been. The Advocacy Council will continue to advocate for strong government enforcement of these and other prior authorization reforms such as the Improving Seniors Timely Access to Care Act.
The second action is an announcement from CMS of expanded prior authorization requirements for certain physician services. While Medicare Advantage (MA) plans are among the heaviest utilizers of prior authorization, traditional Medicare is extremely selective in its use of prior authorization. Currently, traditional Medicare does not use prior authorization for any office-based outpatient service. However, this is about to change.
The CMS notice announces a new demonstration project that will expand the list of services subject to prior authorization, including some office-based outpatient services. The list of services in the demonstration are not medical services typically provided by allergists. Most services are relevant to neurology, orthopedics, and wound care. Allergists should be aware of this new policy as CMS could expand the list of services in the future. Nonetheless, the Advocacy Council has submitted comments voicing concerns about the process.
This demonstration will be tested in selected states in specific MAC jurisdictions beginning on Jan. 1, 2026. The selected MAC jurisdictions are JH, JL, JF, and J15, and the selected states are New Jersey (JL), Ohio (J15), Oklahoma, Texas (JH), Arizona and Washington (JF). The prior authorization reviews will be conducted by a yet-to-be-named third-party entity.
Under the model, participating providers will test new technology-assisted decision-making to help steer patients away from “low-value” care. CMS will reimburse participating providers for a share of the savings the model generates from avoiding these services.
CMS intends to align these processes with MA plans as much as possible to avoid duplicative prior authorization requirements. CMS asserts that the demonstration will “require the same information and clinical documentation that is already required to support Medicare FFS payment but earlier in the process, namely, prior to the service being furnished.”
Submitting a prior authorization request will be voluntary under the model. However, if the provider/supplier does not submit a request, their claim will be subject to prepayment medical review that may involve requests for documentation to support the medical necessity of the targeted item or service.
CMS is exploring how it can incorporate a “gold card” system into the model, which will allow clinicians with high approval rates for their previous PA requests to bypass certain requirements. We’ll continue to monitor and report on any changes for prior authorizations.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
