For years, prior authorization has remained among the most contentious pressure points between payers and providers, but those tensions may finally be seeing tangible improvement.
Over the last year, health insurers have made multiple voluntary commitments to reduce their requirements, federal and state regulators continue to expand the rules, and individual payers have announced their own reductions in recent weeks.
Here’s a breakdown of where things stand:
Voluntary payer commitments
The current reform cycle publicly began in June, when roughly 50 insurers pledged to simplify and reduce prior authorization requirements across commercial, Medicare Advantage and managed Medicaid plans covering 257 million Americans.
An April survey from AHIP and the Blue Cross Blue Shield Association found that participating insurers have collectively eliminated 11% of requirements since then, representing 6.5 million fewer requests. The reduction includes a drop of more than 15% for MA plans. Participating plans have also implemented a 90-day continuity of care policy, honoring existing approvals for benefit-equivalent, in-network services when a patient switches plans mid-treatment.
The industry’s next phase takes effect in 2027, when the cohort of payers have committed to implementing standardized electronic prior authorization submissions and processing at least 80% of electronic approvals in real time. The latest push will apply to services commonly requiring prior auth, including imaging and orthopedic surgeries.
Aetna said it has already standardized 88% of its prior auth volume, while UnitedHealthcare and Cigna have each committed to standardizing at least 70%.
Despite the reported progress, an inaugural Aetna provider survey released in April found that only 36% of providers believe payers reliably deliver on their promises more broadly. The survey polled 827 hospital executives, physicians, nurses, pharmacists and health IT leaders during the first quarter of 2026. Only 44% of respondents believe the payers they work with prioritize clarity and patient well-being. At the same time, 65% of providers said they believe prior auth is necessary in some capacity to assess medical need, hold parties financially accountable and reduce low-value care.
Regulatory changes
At the federal level, CMS has been layering new requirements onto payers while also proposing to extend the current framework even further.
Under the 2024 Interoperability and Prior Authorization Rule, payers were required to begin publicly posting prior auth metrics for the first time, with the first reports covering 2025 data due March 31. Required disclosures include approval rates, denial rates, decision turnaround times and appeals outcomes for medical items and services. MA plans report at the contract level, while Medicaid programs report at the state level. The same rule requires plans to issue decisions on standard prior auth requests within seven calendar days and urgent requests within 72 hours, effective in 2026.
An April analysis by KFF found the initial data offers limited insight, noting that the information is aggregated across all items and services with no breakdown by service type, and payers are not required to report reasons for denials. KFF pointed to Massachusetts and Washington as states offering more granular data, including metrics by service category and prescription drug data, which could serve as models for future collection.
On May 5, CMS Administrator Mehmet Oz, MD, announced the next phase of the initiative, expanding the effort beyond insurers to include hospitals, physician practices, EHR vendors and digital health developers. The new coalition will align on interoperability rule deadlines and address workflow gaps. Under the 2024 rule, payers must also build out a suite of API capabilities by January 1, 2027, covering patient access, provider access, payer-to-payer record transfers and electronic prior auth submission and response. CMS estimates these policies will save approximately $15 billion over 10 years.
Building on that framework, CMS also proposed a rule in April extending the interoperability requirements to cover drugs for the first time. The proposed rule would require Medicaid, CHIP and ACA plans to support three pharmacy data standards by October 2027, enabling providers to query formulary information, check real-time coverage and submit electronic requests for drugs. ACA plans would be required to respond to standard drug requests within 72 hours and expedited requests within 24 hours. The proposal would also expand public reporting requirements to include drugs, require payers to provide specific denial reasons for drug requests, and adopt HL7 FHIR standards for prior auth transactions under HIPAA across all covered entities.
At the state level, at least five states have enacted their own reforms taking effect in 2026.
Latest insurer updates
UnitedHealthcare has steadily reduced prior auth requirements in recent years, eliminating 20% in 2023 and launching a gold carding program in 2024 that exempts some providers for certain services. In April, the company announced exemptions for roughly 1,500 rural hospitals and critical access facilities. In May, it announced an additional 30% reduction targeting outpatient surgeries, diagnostic tests such as echocardiograms, outpatient therapies and chiropractic care, to be completed by year-end. The company said prior auths are currently required for only 2% of medical services, with over 90% of submitted requests approved within 24 hours.
Aetna said it has now standardized 88% of its prior auth volume. More than 83% of its requests are processed in real time, and 95% of eligible requests are approved within 24 hours. The company also said it is the first large payer to integrate medical and pharmacy decisions into single, condition-specific reviews.
Cigna has reduced overall medical prior auth volume by approximately 15%. The company disclosed during its April 30 first quarter earnings call that it is “exploring strategic alternatives” for EviCore, its Evernorth subsidiary that provides utilization management and prior auth services to other payers. Incoming CEO Brian Evanko said the company is considering partnerships or a combination with other organizations, though he noted that no transaction is currently underway. He cited industrywide progress on standardization and automation as factors prompting the strategic review.
Elevance Health said in April that its Health OS platform and other AI tools have lowered prior auth denials by nearly 70%. Elevance also operates a “PA Pass” program that waives requirements for approximately 400 outpatient procedure codes for qualifying large health systems, with 16 health systems across seven states currently enrolled. Another similar program offers real-time approval for roughly 250 outpatient procedure codes for smaller medical groups.
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