Humana to Eliminate Pre-approval Procedures for Medicare Advantage Policies by 2026
In a significant move towards improving healthcare accessibility, Humana, the second-largest provider of Medicare Advantage plans, has joined other signatories in a pledge to streamline prior authorization processes for various health plans, covering nearly 80% of Americans.
Jim Rechtin, President and CEO of Humana, acknowledged the complexity, frustration, and difficulty of navigating the current healthcare system, and reiterated the company's commitment to reducing prior authorization requirements.
Humana's plans to streamline the prior authorization process will primarily focus on eliminating about one-third of prior authorization requirements for outpatient services by January 1, 2026. This reduction will target frequently used diagnostic services such as colonoscopies, transthoracic echocardiograms, select CT scans, and MRIs.
In addition, Humana commits to providing decisions within one business day for at least 95% of fully completed electronic prior authorization requests, improving from the current rate of just above 85% for outpatient procedures.
To further streamline the process, Humana is introducing a "gold card" program that waives prior authorization requirements for providers who consistently submit coverage requests that meet clinical criteria and demonstrate good outcomes for patients. This program aims to reward trusted providers and streamline the process for them.
To enhance transparency and accountability, Humana will start publicly reporting prior authorization metrics in 2026, including the number of requests approved, denied, overturned after appeal, and average decision turnaround times.
These efforts are part of broader industry commitments, aligning with measures by AHIP and other insurers to streamline, simplify, and reduce prior authorizations, increase communication, and improve transparency of the process, all while maintaining necessary safety checks for high-cost or high-risk treatments.
UnitedHealthcare, the largest provider of Medicare Advantage plans, also requires prior authorization for certain services and procedures, but not for emergency or urgent care. 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.
These changes could potentially lead to less waiting for patients and less paperwork for doctor's offices, making the healthcare system more accessible and efficient for all. The commitment was made at a Health and Human Services (HHS) roundtable attended by Secretary Kennedy and CMS Administrator Dr. Oz.
- Humana's policy-and-legislation commitment to reducing prior authorization requirements in health-and-wellness services, such as colonoscopies and MRIs, aligns with general-news measures by AHIP and other insurers in science and medicine, aiming to simplify and streamline the process.
- The streamlined prior authorization process, as proposed by Humana in policy-and-legislation, will not only affect Medicare beneficiaries but could potentiallyTh reduce waiting times for patients and lessen the burden of paperwork for doctor's offices in the realm of health-and-wellness, contributing to a more accessible and efficient healthcare system.
- As part of the broad regulation in the healthcare sector, Humana's plans, which include reporting prior authorization metrics, aim to increase transparency and accountability in policy-and-legislation, encouraging trust and simplicity in the health-and-wellness system.
