Holding Commercial Health Insurers Accountable
“Trust but verify” is a phrase often associated with President Reagan and the need to ensure that treaties enacted with the Soviet Union were being upheld. Today, that wise advice applies equally to commercial health insurers.
That’s why the AHA is engaged in many efforts to protect patients’ health and ensure that medical professionals, not the insurance industry, are making the key decisions in patient care.
In late June, the AHA applauded the administration’s role in facilitating a pledge by several major health insurers to reform prior authorization processes through standardization, volume reductions and minimizing care delays and disruptions.
As adopted, the industry’s retooling plan would apply to patients covered by Medicare Advantage, Medicaid managed care plans, Health Insurance Marketplace plans and commercial plans.
The AHA has long been advocating for such an overhaul, and it is long overdue. Too often, prior authorization has been used in a manner that leads to dangerous delays in treatment, clinician burnout and waste in the health care system. The burdensome requirements often delay patient access to necessary care or lead to treatment abandonment, putting patients at risk — especially those with chronic or serious conditions.
Moreover, prior authorization’s administrative delays and denials add tremendous cost and burden to the health care system, vacuuming up staff time with paperwork and reducing bedside time spent on personal patient interaction. In some cases, hospitals have seen frustration with the system contribute to heightened tensions in clinical settings, placing medical staff at increased risk of workplace violence. These imposed obstacles to optimal patient care can also lead to burnout and exacerbate the already serious workforce shortage by diminishing the joy in the purposeful work of caring — the very thing that draws so many gifted providers to health care in the first place.
For these reasons, it is vitally important that commercial health insurers are held accountable to meet the letter and spirit of their pledge and “walk the walk” of prior authorization reform.
This week, AHA provided recommendations to the Department of Health and Human Services and the Centers for Medicare & Medicaid Services to help ensure that commercial insurance plans are living up to their promise and easing the burden of the complex and time-consuming prior authorization process on patients and providers.
Suggestions include monitoring plans’ progress in fully implementing existing regulations such as the interoperability and prior authorization final rule and reforms issued in the 2024 Medicare Advantage final rule.
Meanwhile, the AHA continues to urge Congress to pass the Improving Seniors’ Timely Access to Care Act of 2025 (H.R. 3514/S. 1816), bipartisan legislation with widespread support in Congress. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.
In addition, the AHA urged Aetna to rescind its recently announced “level of severity inpatient payment” policy set to take effect Nov. 15. The change will create a new category of inpatient stays, enabling Aetna to unilaterally decide to reimburse hospitals at a reduced rate inconsistent with CMS coverage rules and outside of the good faith contract and rate negotiation process. As we made clear, this replacement of longstanding reimbursement policy could erode the transparency consumers rely on to make informed decisions about their care, undermine important regulatory protections that safeguard patients’ coverage, and jeopardize the ability of hospitals to provide high-quality, accessible care to all who need it.
The AHA will continue to work with Congress, the federal agencies, commercial health insurers and all stakeholders to improve the delivery of patient care, reduce costs and decrease regulatory burdens as we work together to advance health in America.