LAS VEGAS — AHIP President and CEO Mike Tuffin delivered a one-year progress report on the multi-partner initiative to modernize and streamline prior authorization during his opening address at AHIP26 on Tuesday.
The coalition, which includes AHIP and several major health plans, has made some headway: Prior authorization volumes have been cut by 11% this year, Tuffin said. That reduction represents about 6.5 million fewer prior authorizations for provider organizations.
The coalition is aiming for an 80% real-time approval rate at the point of care in 2027, said Tuffin, who noted that prior authorization, which comprises 7% of medical services nationwide, helps provide safeguards against wasteful spending.
Prior auth challenges
One lingering roadblock to further progress remains “outdated, error-prone manual processes,” which can increase administrative costs and lead to processing delays, Tuffin said.
“As hard as it is to believe, sitting here in 2026, 45% of the prior authorizations health plans receive come in manually, usually from a fax,” Tuffin said. “We need to move off the fax machines. There’s no way to give a real-time answer to a fax.”
Beginning next year, coalition members will implement a unified framework to standardize prior authorization, Tuffin said. Historically, a single physician practice contracting with different health plans faced distinct submission protocols and clinical documentation requirements. Now, practices that work with coalition plans in 2027 “will have a common, consistent, transparent and predictable experience in submitting the clinical data needed to support prior authorization,” Tuffin said.
In addition, to mitigate care disruptions and administrative friction during member transitions – such as someone switching to Medicaid or the individual market, or changing commercial group plans midyear – approved prior authorizations will now automatically transfer to the new payer for a designated period.
“We are very aware as an industry that patients are interacting with the healthcare system at moments of vulnerability, at moments of extreme stress for themselves and their loved ones,” Tuffin said. “This is all intended to give more peace of mind.”
Simplifying, streamlining the process
Although Humana President and CEO Jim Rechtin agreed with Tuffin’s view that prior authorization is an important tool that “makes healthcare safer,” he said the process should be more seamless and less burdensome.
“The challenge is not that prior authorizations exist. The challenge is they should not be felt by patients,” Rechtin said. “They just should not be felt by patients or members, and that is what we have to fix.”
Humana has eliminated 340 outpatient codes from its prior authorization requirements in an effort to ease provider burden, Rechtin said. The payer currently processes 95% of its prior authorization requests within 24 hours.
Achieving real-time approvals, though, requires a technological commitment from health systems, Rechtin said. Payers have aligned on the standardized clinical data elements required for prior authorization submissions, he noted.
“We are working to get to where [prior authorization is] not even 24 hours – we want that to be in real time,” Rechtin said. “We can create tools. We need providers to use those tools. And, so, we need to work with our provider partners to make that happen.”
A joint effort
Rechtin, who is now about six months into his tenure as AHIP board chair, noted that his discussions with peer healthcare CEOs have revealed a desire to collaborate, find common ground and promote alignment to work toward the common goal of improving healthcare.
“The more that we are focused on what is complicated in the system and how do we make it simpler – whether that’s prior authorizations, or whether that’s provider directories, or whether that’s data exchange – those are the things that are going to make the system better,” Rechtin said. “Simplicity, simplicity, simplicity. That’s the key.”
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