Major insurers to ease prior authorizations ahead of federal crackdown

By Nona Tepper/ March 29, 2023

UnitedHealth Group and Cigna are revamping their prior authorization processes as new federal regulations aiming to ease the burden on providers and patients loom.

UnitedHealthcare will eliminate nearly 20% of existing prior authorizations beginning in the third quarter for its commercial, Medicare Advantage and Medicaid members, the insurer announced Wednesday. Next year, UnitedHealth will implement a "gold card" program through which qualifying providers will simply notify the insurer about pending care rather than request prior authorization. This will eliminate the need for prior authorization in most cases, according to the company.

“We will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure. We hope other health plans make similar changes,” UnitedHealthcare Chief Medical Officer Dr. Anne Docimo said in a news release.

UnitedHealth processes about 13 million prior authorization requests a year; the new policy will reduce that by approximately 3 million, a company spokesperson wrote in an email. The insurer receives about 600 million claims each year, the spokesperson wrote.

Among the expenses that will no longer require prior authorization are medical equipment such as orthopedic support devices and some genetic tests, the UnitedHealth spokesperson wrote. The insurer plans to provide more information about the gold card during the third quarter.

Cigna has removed prior authorization reviews for nearly 500 services and devices since 2020, Dr. Scott Josephs, national medical officer, wrote in an email. Approximately 6% of medical services are subject to Cigna's prior authorization and the insurer uses an electronic process to enable fast responses, a spokesperson wrote in an email.

Humana also uses electronic processes to review requests and has integrated prior authorizations into its electronic health record platform, a spokesperson wrote in an email.

Aetna, Centene, Elevance Health, and Molina Healthcare did not respond to interview requests.

Voluntary actions like these can be seen as insurers attempting to forestall government intervention, said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, a trade group for independent medical practices.

“Plans may see the writing on the wall and they want to get out in front of it, as opposed to getting run over by a regulatory proposal or having Congress do something,” Gilberg said. “They want to have that degree of autonomy.”

Insurers cutting back on unnecessary prior authorizations is a positive development, Molly Smith, vice president for policy at the American Hospital Association, said in a statement. “We continue to urge policymakers to formalize their proposals to streamline the prior authorization process and other related policies,” she said.

Providers complain that prior authorization requirements have exploded in recent years, and that care is being delayed. For example, the Health and Humans Services Department's inspector general reported last year that Medicare Advantage insurers improperly denied 13% of prior authorization requests. Medicare Advantage carriers processed 35.2 million prior authorization requests in 2021, or 1.5 per patient, according to data compiled by the Kaiser Family Foundation.

The Centers for Medicare and Medicaid Services is slated to finalize a proposal next month that would require health insurers to automate prior authorizations, process them more quickly, justify denials and publicly report data on their decisions.

Prior authorization prevents inappropriate, unnecessary and costly care, according to the health insurance trade group AHIP.

“Provider-driven advocacy groups continue to build pressure to limit the use of prior authorization and other utilization management approaches,” spokesperson David Allen said in a statement. “These important tools ensure that the care that patients receive is safe, effective and affordable.”

Because enrollment in Medicare Advantage is increasing and members often have multiple chronic conditions, it makes sense that insurers are handling more requests over time, said Tricia Beckmann, a principal at Faegre Drinker Biddle & Reath. Prior authorization represents one of the few ways insurers can contain costs, which translates into lower premiums, she said.

Insurers could also be reacting to market consolidation among providers. A lack of negotiating leverage could leave them increasingly relying on utilization management to bring down spending, said Sabrina Corlette, co-director at the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy.

Insurers also are employing artificial intelligence to automate prior authorizations, which likely rankles providers, Corlette said. “The use of algorithms and other tech-based approaches to make prior authorization easier on the carrier side and require less staff, less medical professionals, that might be playing a role,” she said.