Major health insurance companies in the United States have announced plans to significantly change a practice long criticized by patients and doctors: prior authorization. This system, which requires healthcare providers to get insurer approval before covering medical treatments, prescriptions, or services, is often blamed for causing delays and complications in patient care.
Dozens of leading insurers, including major players like UnitedHealthcare, Elevance, Aetna, Cigna, and Kaiser Permanente, have committed to making the prior authorization process more efficient and transparent over the next 18 months.
Understanding Prior Authorization
Prior authorization is essentially a requirement from an insurance company that a doctor or other healthcare provider obtain pre-approval for a specific service, medication, or device before providing it to a patient. Insurers state they use this process to help control healthcare costs and ensure patients receive appropriate, evidence-based care.
Why It’s a Major Pain Point
Despite insurers’ stated goals, the implementation of prior authorization has become a source of significant frustration for patients and healthcare professionals alike. Critics argue the process is often:
Time-Consuming: Delays in receiving approval can postpone necessary treatments or procedures, potentially impacting patient health outcomes. Doctors and their staff spend countless hours navigating complex requirements.
Burdensome: Each insurer can have unique forms, procedures, and criteria, creating a lack of uniformity that adds administrative complexity for medical practices.
Stressful for Patients: Waiting for approval can cause significant anxiety, particularly for patients needing urgent care or monitoring for serious conditions like cancer – a phenomenon some call “scanxiety” when waiting for approval for imaging tests.
Leading to Denials: While not every request is denied, data shows it happens. A KFF study of 2023 Medicare Advantage claims, for instance, found that nearly all customers needed prior authorization for some services, and insurers denied approximately 6% of all prior authorization requests.
The increasing prevalence of prior authorization, particularly for expensive services like specialty drugs, imaging, lab tests, and physical therapy, has coincided with rising healthcare costs. The administrative burden and its potential impact on timely care have even drawn political scrutiny, with some critics, like Dr. Mehmet Oz, describing the process as “a pox on the system” that increases overall costs.
The Specific Commitments Made by Insurers
In response to widespread criticism and calls for reform, the participating insurers have outlined several key areas where they promise changes:
Reduced Scope: Insurers aim to decrease the overall number and types of healthcare claims and services that require prior authorization.
Standardization: Efforts will be made to standardize the process for electronic prior authorization requests by the end of next year, which should help streamline submissions for providers.
Expanded Real-Time Responses: The number of prior authorization requests receiving immediate, automated responses will be increased, potentially speeding up approvals for routine services.
Medical Review for Denials: Denied prior authorization requests will be subject to a medical review process, ensuring clinical expertise is involved in challenging coverage decisions.
What These Reforms Could Mean
For doctors and patients, these commitments represent a potential step forward in addressing a significant barrier to timely care. Standardizing processes and reducing the sheer volume of required authorizations could cut down on administrative overhead for practices and speed up access for patients. Expanding real-time approvals and ensuring medical review for denials are also seen as positive steps towards a more efficient and patient-centered system.
While the implementation will unfold over the next 18 months, the insurers’ public acknowledgment of the need for reform and their commitment to specific changes signals a willingness to address long-standing frustrations with the prior authorization process. This development has the potential to ease some of the delays and administrative burdens that have complicated healthcare for years.
