Humana to Eliminate Prior Authorizations for Medicare Advantage Programs by 2026
In a significant move to improve healthcare accessibility and efficiency, Humana, the second largest provider of Medicare Advantage plans, has announced plans to streamline the prior authorization (PA) process for its patients. This commitment was made at a Health and Human Services (HHS) roundtable attended by Secretary Kennedy and CMS Administrator Dr. Oz.
Reducing Prior Authorization Wait Times
Humana plans to reduce prior authorization wait times for Medicare Advantage patients by eliminating approximately one-third of prior authorization requirements for outpatient services by the start of 2026. This includes common diagnostic procedures such as colonoscopies, transthoracic echocardiograms, certain MRIs, and CT scans.
Faster Processing of Prior Authorization Requests
The insurer has also committed to providing decisions within one business day for at least 95% of electronically submitted prior authorization requests by January 1, 2026. This faster processing aims to reduce delays in care and administrative burdens on providers.
Introducing the "Gold Card" Program
Humana will launch a "gold card" program in 2026, which will exempt providers who have demonstrated a consistent record of submitting appropriate coverage requests from prior authorization requirements. This initiative further streamlines care for patients.
Greater Transparency and Modernization
Humana plans greater transparency by publicly reporting prior authorization metrics such as approvals, denials, and average wait times. The insurer will also work towards boosting electronic interoperability to fit existing provider workflows, reducing requests handled by fax or phone.
Nationwide Impact
Humana has joined other signatories in a pledge to streamline prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace, and commercial plans, covering nearly 80% of Americans.
Background
Prior authorizations are tools used by private insurance companies to contain costs, make sure a plan will cover a service, medication, or equipment, and decide if the care is medically necessary, safe, and cost effective.
A survey of physicians by the American Medical Association revealed that, on average, a physician's office completes 39 prior authorizations per week that take at least 13 office hours to complete. Only 1 in 5 physicians appeal a denial, with over half saying the small number is because they lack the resources to file appeals.
Response to Scrutiny
Humana's move to reduce prior authorization requirements may be a response to increasing scrutiny from Congress, CMS, and HHS regarding prior authorization practices in Medicare Advantage.
For instance, Medicare recently announced it will implement prior authorization requirements for certain traditional fee-for-service Medicare services in six states starting next year.
Looking Ahead
Jim Rechtin, President and CEO of Humana, stated that the current healthcare system is too complex, frustrating, and difficult to navigate. He emphasized that Humana is committed to reducing prior authorization requirements and making this process faster and more seamless.
In 2023, Humana had an average of 3.1 prior authorization requests per MA enrollee and a denial rate of 3.5%, according to an analysis by KFF. UnitedHealthcare, the largest provider of Medicare Advantage plans, continues to require prior authorization for certain services and procedures, but does not require it for emergency or urgent care.
As Humana begins publicly reporting its prior authorization metrics in 2026, including data on prior authorization requests approved, denied, and approved after appeal, as well as the average time between submission and decision, patients can look forward to a more efficient and less frustrating prior authorization process.
Science has a significant role to play in Humana's approach towards health-and-wellness, as they aim to use data and modernization to streamline the prior authorization process for Medicare Advantage patients. Regulation is crucial in this context, as Humana's plans to reduce wait times and improve efficiency could potentially impact Medicare, Medicaid Managed Care, Health Insurance Marketplace, and commercial plans, affecting nearly 80% of Americans.
