Aetna Supports Industry Actions to Simplify Prior Authorization

Rhea-AI Summary

Aetna (NYSE: CVS) announced initiatives to streamline prior authorization processes and improve healthcare navigation. The company is implementing bundled prior authorizations for cancer patients needing MRI/CT scans, with plans to expand to cardiology and musculoskeletal conditions. Their prior authorization approval rate exceeds 95% within 24 hours. The Aetna Clinical Collaboration program focuses on improving care transitions, with on-site nurses coordinating patient transfers from hospitals to reduce readmissions. Initially launched for Medicare Advantage members, it will expand to commercial members. Technological improvements include enhanced Aetna Health app features like Smart Compare for provider matching and real-time prior authorization status updates. These changes aim to reduce administrative burden on healthcare providers while improving patient care coordination and transparency.

Positive

• Over 95% of prior authorizations are approved within 24 hours
• Introduction of bundled prior authorizations for cancer patients, reducing administrative burden
• On-site nurse collaboration program to reduce hospital readmissions
• Enhanced digital tools for real-time authorization tracking and provider matching

Negative

• None.

Insights

Healthcare Policy Analyst

Aetna's prior authorization improvements target administrative efficiency while enhancing patient care coordination, positioning CVS Health competitively in healthcare simplification.

Aetna's announcement represents a strategic move in the ongoing industry-wide effort to reduce administrative burden in healthcare. The company is implementing three key initiatives: bundling prior authorizations for cancer patients, enhancing care transitions through the Aetna Clinical Collaboration program, and improving technology interfaces.

The bundling of prior authorizations for cancer imaging is particularly notable. By consolidating multiple authorization requests into a single approval for lung, breast, and prostate cancer patients, Aetna addresses a significant pain point in cancer care coordination. The planned expansion to cardiology and musculoskeletal conditions later this year suggests a systematic approach to reducing fragmentation across high-utilization specialties.

The Aetna Clinical Collaboration program represents an innovative approach to care transitions - a historically problematic area in U.S. healthcare that often leads to readmissions and increased costs. By embedding Aetna nurses directly within healthcare facilities, the company is creating an integrated care model that could meaningfully reduce the 30-day readmission rates that significantly impact both patient outcomes and healthcare economics.

From a competitive standpoint, Aetna's claim of having "one of the shortest lists of treatments requiring prior authorization" positions them advantageously as regulatory and market pressures mount against excessive utilization management. The 95% approval rate within 24 hours for eligible authorizations demonstrates the company is focusing on process efficiency rather than blanket denial strategies that have drawn criticism to the insurance industry.

These initiatives align with broader industry trends toward value-based care models that emphasize coordination and appropriate utilization over transaction volume. For CVS Health, this represents a coherent strategy to differentiate its insurance products while potentially reducing administrative costs associated with fragmented authorization processes.

• Company commits to distinctive actions that will make it easier to navigate the health care system, access care, and achieve better health

HARTFORD, Conn., June 23, 2025 /PRNewswire/ -- Aetna, a CVS Health company (NYSE: CVS), today announced its support of initiatives championed by American's Health Insurance Plans to improve the experience of doctors and patients. Aetna is also committed to leading the market through a comprehensive strategy to make it easier to navigate health care – reducing reviews, simplifying care site transitions, and putting technology to work for healthcare professionals and their patients.

"The American health care system must work better for people, and we will improve it in distinctive ways that truly matter," said Aetna president Steve Nelson. "We support the industry's commitments to streamline, simplify, and reduce prior authorization. We will go beyond prior authorization, building a health care experience for people we serve, and introducing solutions that improve navigation and advocacy for Aetna members."

Aetna already has one of the shortest lists of treatments and procedures requiring prior authorization in the industry. Of eligible prior authorizations, more than 95 percent are approved within 24 hours, with some completed in just a few hours.    

Bundling Prior Authorizations

One area we can simplify is the prior authorization (PA) process. For people with lung, breast, or prostate cancer who need prior authorizations for MRI or CT scans, we are bundling multiple authorization requests into one up front approval.

Later this year, we plan to add additional bundles for cardiology and musculoskeletal conditions. This initial scope has the potential to help thousands of members across our Commercial and Medicare plans and the medical professionals caring for them.

Aetna Clinical Collaboration Program

We have also introduced our Aetna Clinical Collaboration (ACC) program, which focuses on improving care transitions for patients moving between care settings. In this program, our nurses work with other medical professionals to help members get to the most appropriate care setting when they leave the hospital. Our goal is to reduce 30-day readmission rates and emergency room visits, resulting in improved care outcomes and cost savings.

What makes this program unique is that Aetna nurses work on-site at health care facilities, collaborating directly with a patient's care team to coordinate a transition from the hospital to their home or other community care program based on the individual's health needs. By comprehensively supporting a person's health care touch points – medical, pharmacy, mental wellbeing, and other areas – there is a seamless transition to care at home or in a community setting with a proactive care plan in place.

We have successfully launched the ACC program providing support for Medicare Advantage members transitioning out of a hospital setting and reducing hospital readmissions. We expect to expand this program later this year to other facilities, and to commercial members, people under 65 who get their health benefits from their employer.

Technology Enhancements for Both Members and Healthcare Professionals

We are making significant advancements with our digital tools that help members navigate their health care and gain greater transparency. These enhancements focus on enabling real-time status updates if a prior authorization is required.

Recent updates to the Aetna Health app give Aetna members access to features like Smart Compare that helps match members with medical professionals who are suited to the member's health needs and budget. In addition, we provide status badges showing prior authorization progress, expanded information about service quantities (such as hospital stays and physical therapy visits), and clearer explanations of coverage decisions. These improvements allow members to better track their care journey and understand their authorization status without repeatedly contacting their providers for updates.

Aetna is leading the way in transforming the health care experience by reducing friction, partnering more closely with doctors and hospitals, and offering greater visibility. Through these initiatives, doctors can focus more on patient care and less on administrative tasks, while members benefit from clearer communication and simpler health care journeys.

About Aetna

Aetna, a CVS Health business, serves an estimated 36 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental and behavioral health plans, and medical management capabilities, Medicaid health care management services, workers' compensation administrative services and health information technology products and services. Aetna's customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care professionals, governmental units, government-sponsored plans, labor groups and expatriates. For more information, visit Aetna.com (e.g., clinical diagnoses, eligibility criteria, participation in a disease state management program).

About CVS Health

CVS Health is a leading health solutions company building a world of health around every consumer, wherever they are. As of March 31, 2025, the Company had more than 9,000 retail pharmacy locations, more than 1,000 walk-in and primary care medical clinics, a leading pharmacy benefits manager with approximately 88 million plan members, and a dedicated senior pharmacy care business serving more than 800,000 patients per year. The Company also serves an estimated more than 37 million people through traditional, voluntary and consumer-directed health insurance products and related services, including highly rated Medicare Advantage offerings and a leading standalone Medicare Part D prescription drug plan. The Company's integrated model uses personalized, technology driven services to connect people to simply better health, increasing access to quality care, delivering better outcomes, and lowering overall costs.

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SOURCE CVS Health

FAQ

What changes is Aetna (CVS) making to its prior authorization process?

Aetna is bundling multiple authorization requests for cancer patients needing MRI/CT scans into one upfront approval, with plans to expand to cardiology and musculoskeletal conditions. Over 95% of authorizations are approved within 24 hours.

How does Aetna's Clinical Collaboration Program work?

The program places Aetna nurses on-site at healthcare facilities to collaborate directly with care teams, coordinating patient transitions from hospital to home or community care settings to reduce readmissions.

What new features are available in the Aetna Health app?

The app now includes Smart Compare for matching members with suitable healthcare providers, status badges for prior authorization progress, expanded service quantity information, and clearer coverage decision explanations.

Who will benefit from Aetna's new prior authorization changes?

Initially, patients with lung, breast, or prostate cancer will benefit, with planned expansion to cardiology and musculoskeletal conditions across Commercial and Medicare plans.

When will Aetna expand its Clinical Collaboration Program to commercial members?

Aetna plans to expand the program, currently available for Medicare Advantage members, to commercial members (employer-based coverage) later in the year.