Streamlining Prior Authorizations: UnitedHealth and CVS Partner for Efficiency

UnitedHealth Group and CVS Health have announced a significant advancement in simplifying prior authorization processes by standardizing data and submission procedures for over half of their requests. This initiative aligns with the broader industry efforts to streamline administrative tasks, alleviating burdens on healthcare providers and patients. These changes accompany ongoing regulatory compliance requirements designed to simplify drug and medical service approvals.

Over the past year, health insurance leaders like UnitedHealth and CVS have spearheaded efforts to reduce time and complexity in securing prior authorizations. Within a ten-month period, the industry saw an 11% decrease in authorization volumes, amounting to 6.5 million fewer transactions. Medicare Advantage plans experienced a notable impact, with over a 15% decline in authorizations.

Additionally, a new practice is emerging across the industry whereby insurers accept prior authorizations from previous plans for up to 90 days during a policyholder's transition to a new plan. This protocol is set to influence more than 250 million policyholders, with an aim of achieving real-time authorization decisions by 2027.

The Centers for Medicare & Medicaid Services (CMS) finalized a rule in January to enhance interoperability and accelerate prior authorizations. This regulation compels Medicare Advantage, Medicaid, and ACA marketplace plans to address urgent requests within 72 hours and standard requests within seven days. This rule is projected to save approximately $15 billion over the next decade.

Further regulatory measures are under consideration, including proposals for a 24-hour turnaround time for electronic drug authorizations under medical benefits. Health Secretary Robert F. Kennedy Jr. cited commitments from about 80% of the industry to minimize prior authorizations for standard services. By June 2025, a commitment energized by AHIP and the Blue Cross Blue Shield Association engaged over 60 insurers, affecting approximately 257 million Americans in commercial, Medicare Advantage, and Medicaid services.

By the end of the year, UnitedHealthcare anticipates that more than 70% of its authorization requests will utilize the new standardized system without altering current coverage rules or clinical criteria. Aetna, part of CVS Health, has already achieved an 88% standardization rate. This initiative addresses areas that have historically encountered significant friction, such as orthopedic surgeries and specific imaging procedures like CT scans and MRIs.