Humana to Cut Prior Authorizations for Medicare Advantage Plans by 2026

Conceptual image of a seesaw with a piggybank and an oversized pharmaceutical pill balancing on it, could illustrate ideas around cost, savings or inflation around medication — (Image credit: Getty Images)

Most people know the frustration of needing prior authorization from a health plan, often before they're even eligible for Medicare. Now, Humana, the second largest provider of Medicare Advantage plans, has announced it will reduce its use of prior authorizations and speed up the process for others.

Prior authorizations (PAs) are tools widely used by private insurance companies to contain costs. In addition to making sure your plan will cover the service, medication or equipment, PAs are also a way the health plan can decide if the care is medically necessary, safe, and cost effective. 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 analyzation of prior authorization data by KFF.

Humana 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. This commitment was made at a Health and Human Services (HHS) roundtable attended by Secretary Kennedy and CMS Administrator Dr. Oz.

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“Today’s healthcare system is too complex, frustrating, and difficult to navigate, and we must do better,” said Jim Rechtin, President and CEO of Humana in a press release.

“We are committed to reducing prior authorization requirements and making this process faster and more seamless to better support patients, caregivers, physicians, and healthcare organizations,” he added.

UnitedHealthcare, the largest provider of Medicare Advantage plans, continues to require prior authorization for certain services and procedures. However, it does not require it for emergency or urgent care.

How Humana will trim prior authorization wait times

Any way you slice it, prior authorizations are an inconvenience for both patients and doctors, that can slow you down from getting the care or assistance you need. If Humana sees through plans to streamline the process, it could lead to less waiting for patients and less paperwork for doctor's offices.

Another win for consumers is Humana's plan for increased transparency around the prior authorization process. Humana will begin publicly reporting its prior authorization metrics in 2026. This will include data on prior authorization requests approved, denied, and approved after appeal, as well as the average time between submission and decision.

Here is what Humana is planning to do to reduce wait times and the overall burden of prior authorizations:

Eliminating one-third of prior authorizations for outpatient services: By January 1, 2026, Humana will remove prior authorization requirements for approximately one-third of outpatient services. This specifically includes diagnostic services such as colonoscopies, transthoracic echocardiograms, and select CT scans and MRIs.
Focus on electronic submissions and interoperability: Humana is working to support greater adoption of electronic prior authorization requests (ePA) over methods like fax or phone. Their goal is to modernize and streamline the ePA process to expedite approvals and create a more seamless experience for patients and providers.
Faster approval times for electronic requests: Humana commits to providing a decision within one business day for at least 95% of all complete electronic prior authorization requests by January 1, 2026. The company currently provides a decision within one business day for over 85% of outpatient procedures.
National "Gold Card" program: In 2026, Humana will launch a new "gold card" program. This program will waive prior authorization requirements for certain items and services for providers who have a proven track record of submitting coverage requests that meet medical criteria and deliver high-quality care with consistent outcomes for Humana members.

How prior authorizations can impact physicians and patient care

Physicians offices are a nexus point for prior authorizations between patients and insurers and it takes a toll. A survey of physicians by the American Medical Association revealed how prior authorizations impact patient care.

On average, a physician's office completes 39 prior authorizations per week that take at least 13 office hours to complete; 40% of the physicians surveyed have staff who work exclusively on PAs. Only 1 in 5 physicians appeal a denial, with over half saying the small number is because they lack the resources to file appeals (57%).

While eliminating prior authorization requirements by one-third is a significant reduction, the impact will depend on which services are no longer subject to prior authorization. Humana has specified certain diagnostic services like colonoscopies, echocardiograms, CT scans, and MRIs, which is a good start.

This move comes amid increasing scrutiny from Congress and the Centers for Medicare & Medicaid Services (CMS) and HHS, regarding prior authorization practices in Medicare Advantage. Humana's proactive approach may be a response to this pressure and potential federal regulations

At the same time, Medicare recently announced it will implement prior authorization requirements for certain traditional fee-for-service Medicare services in six states starting next year.

Donna joined Kiplinger as a personal finance writer in 2023. She spent more than a decade as the contributing editor of J.K.Lasser's Your Income Tax Guide and edited state specific legal treatises at ALM Media. She has shared her expertise as a guest on Bloomberg, CNN, Fox, NPR, CNBC and many other media outlets around the nation. She is a graduate of Brooklyn Law School and the University at Buffalo.