Leading health insurers across the nation have vowed to reform a controversial practice known for causing delays and complications in medical care. UnitedHealthcare, CVS Health’s Aetna, among others, are planning to limit the healthcare claims requiring prior authorization, streamline procedures, and enable faster response times.
Prior authorization necessitates insurer approval before covering healthcare services, prescriptions, or diagnostic exams. While insurers argue this method prevents excessive treatment and ensures appropriate care, physicians highlight how its expanded and complex application often delays essential treatments. The death of UnitedHealthcare CEO Brian Thompson recently drew public attention to the frequent frustrations with such coverage practices.
Despite previous attempts by insurers to simplify this process, minimal progress has been reported. Now, with new efforts under the spotlight, Dr. Mehmet Oz, the new head of the Centers for Medicare and Medicaid Services, acknowledges the pressure on insurers to act decisively. “There’s public unrest over this issue,” Oz commented during a news conference, adding that insurers face substantial motivation to address the problem and ease patient concerns.
The insurers have committed to modernizing the electronic processing of prior authorizations by the end of the following year, aiming for efficiency. They intend to narrow the number of claims necessitating authorization and honor past approvals when a patient changes insurance providers. The expansion of real-time responses is also on the table, with assurances that denied claims due to clinical reasons will still undergo reviews by medical experts. However, no guarantee exists that reviewers will match specialties with the attending doctors, a common grievance among healthcare professionals.
If these voluntary adjustments fall short, Dr. Oz indicated the current administration is prepared to consider regulatory measures. “Bring solutions or we will impose them,” he stated.
As healthcare costs rise, including those for prescriptions, tests, and therapies, prior authorization is increasingly prevalent. The process complicates obtaining affordable care, says Michael Anne Kyle, a University of Pennsylvania professor specializing in healthcare access. Research by the health policy organization KFF shows that nearly all Medicare Advantage plan users face prior authorization for specific services, especially costly ones like hospitalizations. The study also noted insurers reject about 6% of all requests.
Dr. Ashley Sumrall, a North Carolina-based oncologist, reports seeing heightened prior authorization for necessary tests like MRIs. For her brain tumor patients, such images are vital for assessing treatment effectiveness and planning further care. She explains how delays in approved requests or outright rejections can worsen patient conditions by halting timely intervention and inducing anxiety among patients awaiting crucial results.
The inconsistency in forms and authorization standards further complicates the landscape. Sumrall points out that each insurer has individualized protocols, making the process cumbersome. “A step towards standardizing is a positive shift, especially given the historical reluctance for compromise from insurers,” she added.
Insurers indicate these changes will encompass work-related and individual market coverage, Medicare Advantage, and the Medicaid program, funded at both state and federal levels.