Preventing unnecessary care and medication prescriptions is the primary purpose of prior authorization. Instead, it has all too often led to slower, burdensome delays to critical care for mental health and substance use treatment, but that could soon change.

A group of major insurers – including UnitedHealthcare, Aetna, Cigna Group, Humana, Blue Cross Blue Shield Association and Kaiser Permanente – met with Health and Human Services Secretary Robert F. Kennedy Jr. and Administrator for the Centers for Medicare and Medicaid Services Dr. Mehmet Oz to make commitments around upending prior authorizations across all types of health care – including behavioral health.

During a June 23 press conference, Oz confirmed that while participation in these plans to streamline prior authorization is voluntary for insurers, these companies have committed to working on code reductions and cutting down the number of medical procedures that require prior authorization.

“These measurable commitments – addressing improvements like timeliness, scope and streamlining – mark a meaningful step forward in our work together to create a better system of health,” Kim Keck, president and CEO of the Blue Cross Blue Shield Association, said in a press release. “This is an important foundation to address bigger problems together, at a time when technology and interoperability can deliver real improvements to patient experience.”

By 2027, Oz said paperwork for prior authorizations will be a thing of the past, with nearly all of these exchanges happening virtually through a digital platform dubbed “Fast Healthcare Interoperability Resources.” The platform will standardize the exchange of data between insurers and providers, enabling real-time decision-making on any procedure or type of care that may require prior authorization approvals, rather than wading through weeks of paperwork and back-and-forth documentation.

“CMS is engaging with providers to find out how they can refine documentation procedures, because that’s often where the entire process gets stuck, in the records that never get out of the doctor’s office in a timely fashion,” Oz said during the press conference. “We have patient advocates identifying low-value codes. There are some things we should not be pre-authorizing anymore, and we should stop that – and the insurance industry agrees with that.”

The initial rollout of the prior authorization reform initiative will begin in January 2026. Code reductions, performance targets and continuity of care protections will initially be implemented for physical health conditions. Behavioral health is expected to be integrated into the framework later after the initial groundwork is laid.

“This is going to allow us to next proceed into looking at ideas with pharmacy and behavioral health, so those opportunities and preauthorization processes are accelerated, too,” Oz added.

The history and what to expect

Historically, prior authorization in behavioral health has hindered access to inpatient treatment, approval for therapy and medication-assisted treatment (MAT) for opioid use disorder (OUD) – requiring providers to submit extensive clinical documentation justifying the need for medical necessity.

Meanwhile, adhering to the unavoidable process and justifying care left patients waiting for approval to receive additional therapy sessions, disrupting critical treatment during a mental health or addiction crisis, preventing access to evidence-based treatment or leading to the abandonment of care altogether. An overhaul of legacy prior authorization requirements could lead to many improvements for patients and providers.

“Behavioral Health services such as intensive outpatient services and inpatient stays can often be delayed or denied by burdensome prior authorization requirements,” Glenn Hamilton, the chief medical officer at Evry Health, told Behavioral Health Business. “Their availability will be improved by faster, more transparent and digital prior authorization approvals.”

Dallas-based Evry Health is a business-to-business health insurance company and a member of America’s Health Insurance Plans trade association.

Some states have worked to remove prior authorization barriers for OUD treatment in the past. Still, this sweeping reform, backed by commitments from insurers that provide coverage to around 75% of Americans, has the potential to remove longstanding barriers to behavioral health access.

The insurance companies agreed to standardize metrics around percentages of code reductions requiring prior authorization, timelines, transparency, interoperability and the adoption of electronic prior authorization standards that CMS will roll out.

However, others in the industry remain skeptical about how the rollout will go.

“As cumbersome as the prior authorization process is, I do worry that the cost of insurance will increase due to the potential increase in the number of approvals of more expensive interventions – some portions which inevitably may not be clinically appropriate,” Dr. Cooper Stone, clinical assistant professor of psychiatry and behavioral science at the University of Pennsylvania’s Perelman School of Medicine told BHB. “At least within psychiatry and behavioral health, newer and more expensive treatments do not equate to better efficacy or outcomes.”

Ultimately, narrowing the scope of prior authorization requirements set forth by insurance companies to the codes and procedures most likely to be abused could make the process smoother across all areas of health care and may open doors to reducing other administrative burdens over time.

“At the end of the day, though this is a step in the right direction, I remain skeptical,” Stone said. “There is no ‘free lunch’ and insurance companies are profit-driven. I’d be curious to see how they benefit from this.”

CMS Administrator Oz noted that there is legislation pending that would codify some of the changes, but underscored that the real value is being driven by insurers who came to the table recognizing that “some of the things that are preauthorized just don’t make any sense.”

Prior authorization reforms could also lead the industry toward widespread adoption of value-based care models, HHS Secretary Kennedy said.

“The digitalization and the interoperability of the system is incentivizing and will allow us to do what we ultimately want to do during this administration, which is to begin the transition to outcome-based care and value-based care,” Kennedy said.