AHIP's Jeanette Thornton on Prior Authorization Reform, Midterms

With the midterm elections over and a new Congress set to be seated in January, health plans are preparing to launch one of their most significant voluntary prior authorization reforms to date as health care costs and access remain top concerns for voters.

In April 2026, AHIP, the Blue Cross Blue Shield Association (BCBSA), and participating health plans committed to a standardized approach for submitting electronic prior authorization requests for the majority of medical services, such as orthopedic surgeries and imaging services, including CT scans and MRIs.¹ Plans will adopt the standards on a rolling basis beginning January 1, 2027.

A related commitment targets real-time answers in 2027 for at least 80% of electronic prior authorization approvals submitted with all needed clinical documentation—a goal that does not mean 80% of all requests will be approved instantly.^2,3

In an interview with The American Journal of Managed Care^® (AJMC^®), Jeanette Thornton, MPA, executive vice president of policy and strategy at AHIP, discussed where prior authorization reform fits into the affordability debate, what providers and patients can expect when the standards take effect, and the policy priorities health plans will bring to the next Congress.

Responses were provided in writing and have been lightly edited for clarity.

AJMC: Health care costs and access were major issues for voters in the midterms. Where does prior authorization reform fit in that conversation, and why did health plans move forward with documentation standards now?

Thornton: Voters have made clear that affordability and health care affordability are a priority. Prior authorization is used selectively, less than 10% of the time, and serves as an important safeguard to help ensure patients receive care that is safe, evidence-based, and as affordable as possible—particularly at a time when experts broadly agree that up to 25% of all health care delivered in America is wasteful at best or, at times, even harmful. Without prior authorization, employers and consumers would face a 5% increase in their premiums annually—a trend that is unsustainable amid other rising medical costs.

That said, we understand the experience can be very frustrating, and that is why health plans are simplifying and streamlining prior authorization so that patients can have faster responses, ideally at the point of care, and providers experience less administrative burden.

Prior authorization reform will speed up access to care and eliminate errors that currently occur when manual processes like faxes are used to submit prior authorization. As part of these commitments, health plans are making continued progress to meaningfully increase the percentage of real-time responses on electronic prior authorization requests in 2027, with the goal of 80% of all prior authorizations submitted electronically with all the necessary information being answered in real time. A standardized approach for providers to submit required information will aid health plans in receiving complete information. That's why participating plans aligned common documentation standards earlier this year, so providers and their technology partners have time to build them ahead of January 1, 2027.

AJMC: AHIP and BCBSA's standards cover 66 services, with implementation targeted for January 1, 2027, just days before the new Congress is seated. What will be different for providers and patients on day 1?

Thornton: Starting in 2027, providers who have done away with error-prone manual processes and embraced electronic prior authorization will see the benefit of standardized approaches to submission with faster turnaround times on responses. Patients will have a more streamlined, seamless, and transparent experience, with clearer communication when prior authorization is needed.

AJMC: Prior authorization has drawn scrutiny from lawmakers in both parties. How do these voluntary industry standards fit alongside potential legislative or regulatory action, and could the new balance of power in Congress change that dynamic?

Thornton: Health plans will continue to engage with policy makers on the industry's continued progress to streamline and simplify prior authorization. In certain cases, the industry's voluntary commitments meet or exceed federal and state standards around prior authorization, particularly related to response times. Health plans welcome any opportunity to work with policy makers on common-sense improvements that expand access and reduce barriers to care.

AJMC: The standards apply across Medicare Advantage, Medicaid managed care, and commercial coverage, but only where federal or state rules don't supersede them. How might the midterm results at the federal and state levels affect how plans implement them?

Thornton: Health plans must comply with applicable state and federal laws. In some cases, states regulating the commercial market or Medicaid programs require the submission of specific information to support prior authorization reviews, and plans will have to follow these requirements. In all other cases, these standards will apply. Each plan determines its medical policies and coverage benefits consistent with applicable federal and state law.

AJMC: AHIP's 2026 analysis found that nearly two-thirds of commercial premium dollars go to hospital and prescription drug costs. With affordability a key campaign issue, what policy priorities will AHIP bring to the next Congress beyond prior authorization?

Thornton: Health plans are doing everything in their power to shield consumers from the full impact of high and rising medical costs. While health plans play a central role in making health care as affordable as possible, commonsense policy solutions are needed to address the root causes of high and rising costs. Health plans support bipartisan policy solutions to lower health care costs for everyone, including:

• Encouraging competition by stopping anticompetitive hospital mergers that raise costs;
• Passing site-neutral payment reforms;
• Curbing pharmaceutical patent abuse and accelerating availability of biosimilars; and
• Reforming the independent dispute resolution process, which is being abused by certain private equity–backed providers.

AJMC: AHIP plans to add more services and establish ongoing governance beginning in 2027. What should the incoming Congress and patients expect from this effort over the next 2 years, and how will progress be reported?

Thornton: The work to standardize additional prior authorization services will continue in 2027, building upon lessons learned from implementation in January.

At the time the commitments were made, roughly half of prior authorization requests still arrived from providers by error-prone manual processes such as fax, phone, or email, leading to delays and incomplete submissions. Looking ahead to 2027, we will continue to partner with providers to abolish the faxes and paperwork so we can have a more trusted real-time system. Standardization and provider adoption of electronic prior authorization will help reduce initial denials and achieve faster responses for patients. These 2 commitments represent a substantial technical and operational undertaking that will ultimately enable most prior authorizations to be routinely approved at the point of care while giving providers a faster and more consistent experience.

References

1. Health plans take next step to streamline and simplify prior authorization for patients and providers. News release. Blue Cross Blue Shield Association. April 24, 2026. Accessed November 11, 2026. https://www.bcbs.com/about-us/association-news/prior-authorization-standardization

2. 2026 will bring progress on simplifying prior authorization. Blue Cross Blue Shield Association. Accessed November 11, 2026. https://www.bcbs.com/news-and-insights/article/simplifying-prior-authorization

3. Steinzor P. FAQ: prior authorization reform—will changes go far enough by 2027? AJMC. August 26, 2026. Accessed November 11, 2026. https://www.ajmc.com/view/faq-prior-authorization-reform-will-changes-go-far-enough-by-2027-