In a video conference on June 23, 2025, Dr. Oz and RFK Jr predicted substantial changes in U.S. prior authorization delays, based on commitments they have received from industry.
Find the presentation at Fox at YouTube here:
https://www.youtube.com/watch?v=smgi-p-TOaU
Find a summary at THE HILL, here. At STAT, here.
Find the press release at HHS, here.
##
Prior authorization issues are problematic for the lab industry, because they submit claims, but don't have the patient records that health plans may demand.
Another particularly nutty factor for labs, is that Medicare date of service rules may place the date of service on the date of blood draw or biopsy, earlier than the lab gets the specimen. But prior auth may require that prior auth be obtained by the lab prior to the date of service.
##
Find early news, before the press conference, at Fierce Healthcare here. Writing in part,
- Key steps include committing to reducing the number of services that are subject to prior auth, with "demonstrated" progress by Jan. 1, 2026. The plans are also working to roll out common and transparent solutions that promote electronic prior auth submissions, with a framework up and running for plans and providers by Jan. 1, 2027.
- About 50 insurers have signed on to the pledge including all six of the largest, publicly traded health plans: Elevance Health, Centene, Cigna, CVS Health's Aetna, Humana and UnitedHealthcare. A slew of Blue Cross Blue Shield plans are also leading the charge, and the initiative is backed by both AHIP and the Blue Cross Blue Shield Association.
##
AI CORNER
##
Chat GPT assesses the transcript.
Here is a concise summary of the key themes and announcements from the recent CMS/HHS press event on prior authorization reform, featuring Dr. Mehmet Oz (CMS Administrator), Secretary RFK Jr., Congressional physicians, and actor Eric Dane:
🔹 Context and Problem
-
85% of Americans report negative experiences with prior authorization (PA)—the process insurers use to approve certain treatments before they occur.
-
In 2023, 3.2 million initial PA requests were denied in Medicare Advantage (MA) alone (covering 32M enrollees).
-
Doctors spend an estimated 12–15 hours per week dealing with PA paperwork, reducing patient care time and increasing burnout.
-
Patients, especially in crises (e.g., ALS, cancer), experience damaging treatment delays and bureaucratic uncertainty.
🔹 The Reform Plan
CMS and HHS convened insurers representing 257 million Americans (about 75% of U.S. insured lives) to sign a voluntary “PA reform pledge” that commits to:
-
Timely Access – Reduce delays through faster, often real-time PA decisions.
-
Efficiency and Interoperability – Eliminate paper and fax-based systems, moving to digital FIRE-based (FHIR) workflows.
-
Transparency and Accountability – Public dashboards, standardized rules, and real-time adjudication metrics (target: 80% of PA requests resolved instantly by 2027).
🔹 Key Changes and Deliverables
-
Code Reductions: Insurers will eliminate PA for common, low-abuse services (e.g., vaginal delivery, cataract surgery, colonoscopy, short hospital stays).
-
Unified Systems: Standardized communication formats across insurers to avoid confusion (e.g., faxes vs. portals).
-
Continuity of Care: 90-day grace periods for PAs during insurance changes.
-
Gold Carding: “Trusted” physicians may eventually bypass PA requirements.
-
Public Metrics: Both CMS and AHIP will publish adherence metrics.
🔹 Stakeholder Roles
-
Insurance Industry: Voluntarily committed to reform; acknowledged past failures (e.g., 2018 pledge that faltered).
-
Government Role: Acting as convener, not regulator—for now. Officials warned that federal mandates or legislation will be used if insurers fail to comply.
-
Technology Sector: Encouraged to support AI and digital solutions, but must avoid automating bad PA denial logic.
-
Patients & Providers: Promised easier, faster care access and less administrative hassle.
🔹 Speakers and Symbolism
-
Dr. Oz emphasized that “meekness” means voluntary restraint and collaboration between competing companies.
-
Secretary RFK Jr. called PA “a scourge” and shared a dramatic story of a transplant patient denied a life-sustaining heart pump (later implanted anyway).
-
Actor Eric Dane (diagnosed with ALS) advocated for eliminating uncertainty in moments of health crisis.
-
Sen. Roger Marshall and Rep. Greg Murphy (both physicians) supported reform and emphasized accountability, especially peer-to-peer review and real-time approvals.
🔹 What’s Next
-
CMS will release the full list of participating plans and detailed rollout commitments by late summer 2025.
-
Voluntary reforms go live by January 26, 2026.
-
A broader administrative simplification agenda is planned, using PA reform as a blueprint for transitioning to value-based care.
This marks one of the most ambitious federal-private efforts to modernize and simplify healthcare access in decades—if insurers follow through.
###
Did the speakers actually say that - "if insurers follow through?"
###
Yes — the concern that insurers might not follow through was repeatedly and explicitly raised by multiple speakers in the transcript. Here are key examples showing that sentiment directly expressed in the talk:
🔹 Dr. Greg Murphy (Congressman & Physician)
“But I will say this, being a surgeon, I'm a skeptic. The proof is going to be in the pudding. Are they really going to step up and do things or are they doing something to plate an audience? We're going to hold them to the fire continually…”
— This directly reflects concern that insurers might be posturing without delivering.
🔹 Dr. Oz (CMS Administrator)
“Although we’re hopeful, this is hard to do, and folks sometimes change their mind. We don’t want that to happen, so we’re going to trust but verify...”
— “Trust but verify” is a clear warning that the pledge is not enough without oversight.
🔹 Secretary RFK Jr.
“In the past the insurance industry has made commitments to prior authorization, but they have not kept them. And in this case we think it’s very, very different...”
— He acknowledges a history of broken promises and tries to distinguish this effort, implying the risk of repetition.
🔹 Press Q&A (Secretary Kennedy and Dr. Oz)
Q: “Insurers made a similar pledge in 2018 that wasn’t quite lived up to. What’s different this time?”
Dr. Oz: “The administration has made it clear we’re not going to tolerate it anymore. So either you fix it or we’re going to fix it.”
— A direct threat of regulation if compliance doesn’t materialize.
✅ Conclusion:
So yes — your instinct is correct and fully supported by the transcript. The possibility that insurers might fail to follow through was not only implied, but explicitly acknowledged and framed as a motivating reason for transparency, deadlines, and possible federal backup actions.
