How Payers Are Reducing Prior Authorizations, Limiting Care Disruptions
To limit patient care disruptions, payers have reduced prior authorization requirements for genetic testing, cataract surgeries, and physical therapy.
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- Although prior authorization aims to control costs and limit unnecessary medical procedures, healthcare stakeholders have continued to raise concerns that the process creates substantial administrative burden for providers and disrupts patient care.
As prior authorization scrutiny persists, payers have started to reduce requirements and limit these care disruptions.
Some payers have scaled back on requirements for certain codes, while others have implemented electronic prior authorization tools to streamline the process.
UnitedHealthcare
UnitedHealthcare’s prior authorization policies have been in the spotlight recently. In March 2023, the payer announced that it would eliminate almost 20 percent of prior authorization requirements in the summer to help simplify the healthcare experience for consumers and providers.
In August 2023, UnitedHealthcare shared its two-phased approach to removing prior authorization requirements for specific codes across different health plans.
READ MORE: AHIP, BCBSA Voice Concerns About Proposed Prior Authorization Rule
Starting September 1 in commercial plans, the following service categories will see reductions in prior authorization: durable medical equipment/orthotics/prosthetics, hysterectomy, spine surgery, genetic testing, breast reconstruction, cardiology, radiology, and outpatient therapies.
Under UnitedHealthcare Medicare Advantage plans, vein procedures, durable medical equipment, breast reconstruction, radiology, orthotics/prosthetics, hysterectomy, and spine surgery services will be available for reduced prior authorization.
The utilization management process will be removed for similar service categories in individual exchange plans.
The payer plans to remove codes in commercial, Oxford, individual exchange, and Medicare Advantage plans on both September 1 and November 1, while codes under the UnitedHealthcare community plan will be eliminated on November 1 only.
The full breakdown and specific codes can be found here.
READ MORE: Healthcare Organizations Oppose UHC’s GI Prior Authorization Program
While UnitedHealthcare acknowledged that prior authorization is an important tool to address clinical quality, safety, and healthcare fraud, the payer said it aims to streamline care delivery by minimizing requirements.
The payer also indicated that it will implement a national Gold Card program for eligible provider groups in 2024. These groups will follow an administrative notification process for most procedure codes instead of the prior authorization process. The program will apply to UnitedHealthcare members across commercial, Medicare Advantage, and Medicaid plans.
The payer said it will provide more information about the Gold Card program later this year.
UnitedHealthcare also launched a resource for members to track prior authorization requests on myuhc.com or the UnitedHealthcare mobile app.
In addition to the payer removing prior authorization for 20 percent of codes, the plan recently rolled back a gastrointestinal (GI) endoscopy prior authorization program. The program was going to require prior authorization for most GI endoscopic procedures.
READ MORE: Medicare Advantage Final Rule Addresses Prior Authorization, Health Equity
Over 170 healthcare organizations expressed concern about the program, stating that it would increase provider burden and limit patient access to care. After meeting with provider groups and speaking with the American Hospital Association (AHA), UnitedHealthcare announced a refocused policy requiring advance notification instead of prior authorization for gastroenterology endoscopy services.
Humana
Humana has reduced care disruptions for Medicare Advantage beneficiaries in Georgia by eliminating its prior authorization requirement for cataract surgery that it announced in August 2022. The payer started requiring pre-approval through iCare Health Solutions for cataract and posterior capsulotomy surgeries, leading to treatment delays and denials for beneficiaries needing surgery to restore sight.
The announcement received pushback from the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, and the Georgia Society of Ophthalmology. The organizations applauded Humana’s decision to roll back the requirement, effective August 1, 2023.
Around 4 million Americans receive cataract surgery each year, and the procedure has a high success rate, improves quality of life, and is associated with reduced cognitive decline among older adults.
“We commend Humana for listening to patients and physicians and removing barriers to timely cataract surgery,” Stephen D McLeod, MD, CEO of the American Academy of Ophthalmology, said in the press release. “Requiring approval for a routine, well-established procedure only serves to delay a transformative treatment, and bind physicians in unnecessary red tape.”
Aetna
Aetna made similar changes to prior authorization for cataract surgeries in July 2022. The payer eliminated pre-certification requirements for most health plan members. However, this amendment did not include Medicare Advantage beneficiaries in Florida and Georgia.
The health plan also ended prior authorization for physical therapy in Delaware, New Jersey, New York, Pennsylvania, and West Virginia. The American Physical Therapy Association said the decision aligned with its advocacy to reduce the excessive use of prior authorization at the commercial and federal payer levels.
The Association noted that removing prior authorization requirements would allow physical therapists to demonstrate their commitment to sound clinical decision-making and responsible care.
Health Care Service Corporation
Payers are also leveraging technology to streamline prior authorization processes. For example, Health Care Service Corporation (HCSC), which operates health plans in Illinois, Montana, New Mexico, Oklahoma, and Texas, has incorporated artificial and augmented intelligence into its prior authorization process.
The insurer expanded the use of an augmented intelligence tool that accelerates the prior authorization process up to 1,400 times faster. The tool streamlines the submission process and provides auto-approvals when certain criteria are met. The resource can triage and approve requests that require minimal information, allowing clinical staff to focus on reviewing more complex requests.
HCSC also improved its artificial intelligence capabilities to speed up prior authorization approvals by using algorithms that approve care for treatments almost instantly. The algorithm uses historical authorizations and claims to identify the data required to authorize treatment.
Using electronic prior authorization processes over manual submissions can reduce the turnaround time of approvals by nearly 70 percent, according to AHIP. In cases that continue to require prior authorization, automating the process can help limit care delays for those awaiting treatment.
