UnitedHealthcare is keeping the momentum rolling with prior authorization reform, promising even more reductions by year's end.
United announced today that it plans to reduce prior authorizations by another 30% in 2026. The payer was also part of a group of over 50 leading health plans that touted an 11% reduction in prior authorizations last month.
Paring back prior authorizations is part of a pledge the payers took in 2025 to reform the notoriously burdensome process. The payers, which also included Cigna, Aetna, Elevance Health and several Blues plans, also agreed to other reforms, such as digitizing prior authorizations, ensuring continuity of care when patients change plans and expanding real-time responses.
United said in the announcement that it will no longer require prior authorizations for some outpatient surgeries and therapies, as well as chiropractic care. Some diagnostic tests, like echocardiograms, will also no longer require prior approvals from the payer.
The payer already eliminated most prior authorizations for rural providers across all lines of business in an effort to bolster a strained rural healthcare system.
"Prior authorization is an essential safeguard but should only be used when it truly protects patients and improves care," Tim Noel, United's CEO, said in a press release.
But this is not the end of United's prior authorization reforms, Noel continued. He said United is "committed to further improving and refining our processes to make reviews quicker, simpler and more efficient."
Last month, the payer signed on to an industrywide effort to standardize submission requirements for electronic prior authorizations. It said more than half of its prior authorization volume will be included in the initiative, with a goal of 70% by the end of the year.
United explained that the electronic prior authorization standards are part of "the next phase of the payer's ongoing efforts to modernize and simplify prior authorizations."
Making strides with prior authorization reform
Prior authorizations are a major challenge for healthcare providers and patients, who say the process takes away from direct care, delays treatment and can even lead to injury and death in some cases.
Leading payers are recognizing the toll this utilization management strategy is taking on the healthcare industry. They maintain that prior authorizations are necessary to curb unnecessary care, especially as healthcare costs continue to soar, but reform is needed.
And they have already made major strides. America's Health Insurance Plans and the Blue Cross Blue Shield Association recently reported an overall reduction in the scope of prior authorizations, particularly in Medicare Advantage, where a 15% reduction was observed.
Some payers have also established secure data-sharing processes for better continuity of care.
Payers like United have also adopted so-called "gold cards," which exempt some providers from prior authorization requirements if they consistently adhere to evidence-based care guidelines. United reported that it plans to expand its nationwide gold-card program, which experienced a 40% increase in the number of qualified provider groups last year.
More payers are also using AI to streamline and automate prior authorizations. This is in part to CMS' Wasteful and Inappropriate Service Reduction, or WISeR, Model that requires the use of AI and machine learning for prior authorizations for select high-risk Medicare services in six states. The agency kicked off the WISeR Model at the start of the year.
Miles to go
Despite progress across several areas, prior authorizations remain one of the most burdensome processes in healthcare. Industry critics continue to call for stricter, faster and more transparent decision timeframes, more standardization of requirements and continued automation of the process.
United is among the many private payers committing to further advancements. However, the federal government is accelerating reform through new and proposed policies.
CMS has started implementing the 2024 Interoperability and Prior Authorization final rule, already requiring some health plans to use a standardized application programming interface to automate prior authorization approvals and reduce decision timeframes to a standard of 7 days (from 14) and 72 hours for expedited requests. Through the API, impacted payers must also provide a denial reason.
Next year, these plans will need to implement two more APIs -- one for payer-to-payer transferring of records during patient transitions and one for patient access to prior authorization information.
CMS also recently proposed expanding API requirements to include detailed drug prior authorization data, including denial reasons and dosages by Oct. 1, 2027.
Healthcare payers have generally supported CMS' policy efforts to improve prior authorizations, although they have expressed significant concerns with tight compliance timelines, high implementation costs and technical challenges in developing API infrastructure.
A recent report from the Peterson Health Technology Institute also warned of the limitations of AI for prior authorizations. Researchers said applying AI could exacerbate core issues with an already flawed process, leading to higher costs to the overall healthcare system.
Some lawmakers have also sought to repeal the WISeR Model, contending it will add administrative burden and limit access to care for Medicare beneficiaries.
While payers like United continue to pledge progress, the healthcare industry faces a delicate balancing act: streamlining a process that providers and patients find burdensome while addressing legitimate concerns about implementation challenges and unintended consequences.
Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.
