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How CVS' Aetna Is Advancing Efforts to Reduce Administrative Burden
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Key Takeaways
CVS Aetna has the fewest services requiring prior authorization, about half as many as its nearest rival.
CVS Aetna approves 77% of electronic prior authorizations in real time, targeting more than 80% by year-end.
CVS expanded bundled cancer authorizations to all cancer types for eligible Medicaid members on Sept. 1.
CVS Health (CVS - Free Report) is working to make health care easier to navigate. The company’s insurance arm, Aetna, has the fewest medical services subject to prior authorization, about half as many as its nearest competitor. More than 95% of all eligible prior authorizations are approved within 24 hours, with many approved instantly. Aetna currently approves 77% of electronic prior authorizations in real time and expects to exceed 80% by year-end.
Administrative burden remains a significant challenge for healthcare providers. In Aetna's latest survey, 74% of respondents identified it as the top challenge facing clinical staff. Prior authorization management alone accounted for the biggest administrative burden for 31% of respondents. By streamlining approvals, Aetna aims to give clinicians more time to focus on patient care.
Aetna introduced bundled prior authorizations last year to cover multiple tests and treatments under a single request. The program started with lung, breast and prostate cancer screenings and interventions. It later expanded to certain musculoskeletal procedures, including X-rays, knee arthroplasty surgical procedures, anti-nausea and non-opioid pain medications, inpatient admission, infection control and durable medical equipment. The insurer has also started bundling authorizations for in vitro fertilization (IVF)-related prescriptions and medical procedures.
As of Sept. 1, Aetna expanded bundled prior authorizations to all cancer types for members in eligible Medicaid states. Nearly 25% of eligible members received a bundled authorization during the initial rollout, allowing services to be approved in advance and helping speed access to care. The bundles combine medical oncology, including chemotherapy and immunotherapy where appropriate, and/or radiation oncology with advanced imaging, such as MRI and CT scans, in a single request submitted through one portal.
Aetna plans to extend the program across all lines of business in 2027, with Medicare and Commercial members expected to become eligible in the first half of the year.
Updates From CVS Peers
Humana (HUM - Free Report) has entered into a new joint venture agreement with funds and accounts managed by HPS Investment Partners, part of BlackRock, to manage and operate nearly 150 existing CenterWell Senior Primary Care clinics. The clinics currently operate under joint ventures owned by funds affiliated with WCAS and CenterWell. Under the new arrangement, BlackRock will hold a majority stake, while CenterWell will retain a minority interest. The venture will replace the existing partnerships that helped scale CenterWell into the nation’s largest senior-focused value-based primary care provider over the past seven years. The new structure is expected to give Humana access to additional growth capital and improve its financial flexibility.
The Cigna Group (CI - Free Report) announced a collaboration with OpenAI to enhance outcomes for patients with complex health conditions. The partnership will bring OpenAI’s frontier reasoning capabilities into clinical workflows and customer experiences across The Cigna Group ecosystem to deliver more personalized support. The initial focus will be cancer care, with new capabilities designed to identify emerging patient needs earlier, personalize assistance and strengthen care coordination throughout treatment. The collaboration is expected to expand over time, creating a broader range of health intelligence capabilities for patients with various medical conditions.
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How CVS' Aetna Is Advancing Efforts to Reduce Administrative Burden
Key Takeaways
CVS Health (CVS - Free Report) is working to make health care easier to navigate. The company’s insurance arm, Aetna, has the fewest medical services subject to prior authorization, about half as many as its nearest competitor. More than 95% of all eligible prior authorizations are approved within 24 hours, with many approved instantly. Aetna currently approves 77% of electronic prior authorizations in real time and expects to exceed 80% by year-end.
Administrative burden remains a significant challenge for healthcare providers. In Aetna's latest survey, 74% of respondents identified it as the top challenge facing clinical staff. Prior authorization management alone accounted for the biggest administrative burden for 31% of respondents. By streamlining approvals, Aetna aims to give clinicians more time to focus on patient care.
Aetna introduced bundled prior authorizations last year to cover multiple tests and treatments under a single request. The program started with lung, breast and prostate cancer screenings and interventions. It later expanded to certain musculoskeletal procedures, including X-rays, knee arthroplasty surgical procedures, anti-nausea and non-opioid pain medications, inpatient admission, infection control and durable medical equipment. The insurer has also started bundling authorizations for in vitro fertilization (IVF)-related prescriptions and medical procedures.
As of Sept. 1, Aetna expanded bundled prior authorizations to all cancer types for members in eligible Medicaid states. Nearly 25% of eligible members received a bundled authorization during the initial rollout, allowing services to be approved in advance and helping speed access to care. The bundles combine medical oncology, including chemotherapy and immunotherapy where appropriate, and/or radiation oncology with advanced imaging, such as MRI and CT scans, in a single request submitted through one portal.
Aetna plans to extend the program across all lines of business in 2027, with Medicare and Commercial members expected to become eligible in the first half of the year.
Updates From CVS Peers
Humana (HUM - Free Report) has entered into a new joint venture agreement with funds and accounts managed by HPS Investment Partners, part of BlackRock, to manage and operate nearly 150 existing CenterWell Senior Primary Care clinics. The clinics currently operate under joint ventures owned by funds affiliated with WCAS and CenterWell. Under the new arrangement, BlackRock will hold a majority stake, while CenterWell will retain a minority interest. The venture will replace the existing partnerships that helped scale CenterWell into the nation’s largest senior-focused value-based primary care provider over the past seven years. The new structure is expected to give Humana access to additional growth capital and improve its financial flexibility.
The Cigna Group (CI - Free Report) announced a collaboration with OpenAI to enhance outcomes for patients with complex health conditions. The partnership will bring OpenAI’s frontier reasoning capabilities into clinical workflows and customer experiences across The Cigna Group ecosystem to deliver more personalized support. The initial focus will be cancer care, with new capabilities designed to identify emerging patient needs earlier, personalize assistance and strengthen care coordination throughout treatment. The collaboration is expected to expand over time, creating a broader range of health intelligence capabilities for patients with various medical conditions.