What's the news: The country’s No. 1 health insurer, UnitedHealthcare (UHC), and another insurance giant—Cigna Healthcare—recently announced tentative steps to reduce the volume of care-delaying, time-wasting prior authorizations they require.
Starting this month, several UnitedHealthcare plans will start eliminating the prior authorization requirement for many procedure codes that the insurer says account for nearly 20% of its overall prior authorization volume. The company also said that next year it will implement a “gold card” program allowing those who qualify to follow a “simple administrative notification process for most procedure codes” instead of prior authorization. Cigna, meanwhile, said it is removing nearly 25% of medical services from prior authorization requirements.
The insurers’ efforts “begin to reduce the overwhelming volume of prior authorization requirements that are threatening patients’ health and wasting valuable health care resources,” said AMA Immediate Past President Jack Resneck, MD.
“The actions taken by UHC and Cigna appear to be a step in the right direction and in line with components of the consensus statement [PDF] to improve the prior authorization process, which was agreed to by insurers in 2018,” added Dr. Resneck, a San Francisco Bay Area dermatologist. “As we evaluate the real impact of these changes, we remain cautiously optimistic that patients and physicians will begin to feel some relief from the prior authorization burden under these plans.”
The UHC and Cigna announcements come after years of apathetic or ineffectual follow-through by health insurers on mutually accepted prior authorization reforms, with many other insurers failing to make the agreed upon changes, as demonstrated in the most recent AMA survey of physicians (PDF). Dr. Resneck said the AMA is “careful not to confuse positive developments with major progress,” noting that “prior authorization remains a major obstacle to timely and necessary care for our patients and an overwhelming burden to physicians.”
UHC’s recent implementation of an advance-notification program for nonscreening gastroenterology endoscopies supports the AMA’s cautious response. While the program only requests that physicians submit supporting documentation to the insurer and does not result in medical necessity denials, it still increases administrative hassles for practices.
Moreover, UHC will be using the data from this program to determine eligibility for its gold-carding program in 2024—suggesting that these endoscopy services may be added to the insurer’s prior authorization list.
Fixing prior authorization is a critical component of the AMA Recovery Plan for America's Physicians.
Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.
Why it’s important: While payers often claim that prior authorization requirements are used for cost and quality control, an overwhelming majority of physicians report that the protocols lead to unnecessary waste and avoidable patient harm. One-third of the 1,001 physicians surveyed (PDF) by the AMA in December reported that prior authorization has led to a serious adverse event for a patient in their care.
More specifically, the AMA survey found that these shares of the physician respondents reported that prior authorization led to:
- A patient’s hospitalization—25%.
- A life-threatening event or one that required intervention to prevent permanent impairment or damage—19%.
- A patient’s disability or permanent bodily damage, congenital anomaly or birth defect, or death—9%.
That’s why regulatory and legislative actions at the state and federal levels are needed.
“The AMA is committed to right sizing this bloated process,” Dr. Resneck said. “In line with the consensus statement, the AMA is urgently working on all fronts for further reductions in prior authorization volume, as well as other critical steps, including protections for patient continuity of care, gold-carding programs for physicians, and improved transparency and automation.”
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This summer, the powerful House Ways and Means Committee advanced provisions that would help bring badly needed reforms to the prior-authorization process within Medicare Advantage. The provisions hew closely to the Improving Seniors’ Timely Access to Care Act.
The House Ways and Means Committee passage came on the heels of a bipartisan, bicameral letter to HHS and the Centers for Medicare & Medicaid Services (CMS) urging the agency to finalize a pending federal regulation that would overhaul prior-authorization requirements within Medicare Advantage.
Ultimately, 61 Senators cosigned the letter, along with 233 House members. The AMA helped spearhead support for the letter, and the AMA’s Physicians Grassroots Network and Patients Action Network worked to ensure a robust number of members of Congress cosigned this important communication to CMS.
Learn more: Patients, physicians and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.
Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.
