Health plans pledge to simplify pre-treatment reviews
Why it matters: Insurers maintain that requiring a sign-off before patients care get care is necessary to control costs and make sure treatments and medications are safe and effective.
But more than 8 in 10 physicians said that issues with prior authorization requirements led patients to abandon treatment, according to an American Medical Association survey last year. Nearly 90% said prior authorizations contribute to burnout.
State of play: Leading health plans today will voluntarily commit to answer at least 80% of electronic prior authorization requests that have the necessary clinical documentation in real time by 2027.
The insurers also said they'll work to create common electronic prior authorization submission requirements for plans and providers by Jan. 1, 2027.
The commitments cover all insurance markets, including private health plans and Medicare Advantage.
AHIP and the Blue Cross Blue Shield Association led the commitments. UnitedHealthcare, Aetna CVS Health, Cigna, Elevance and Kaiser Permanente are among the other companies on the pledge.
Each is committing to reduce the claims subject to prior authorization "as appropriate for the local market" by the start of next year, according to a joint news release.
The insurers will also honor prior pre-treatment approvals when patients change plans during the course of treatment over a 90-day transition period.
What they're saying: Physicians offered measured approval of the initiative.
"While this commitment is a step in the right direction, we will ultimately measure its impact by real changes in the day-to-day experiences of patients and the physicians who care for them," Shawn Martin, CEO of the American Academy of Family Physicians, said in a statement included in insurers' news release.
Flash back: Major trade associations for health insurers, physicians, hospitals and pharmacists released a consensus statement in 2018 on improving prior authorization, but patient and provider concerns have persisted.
Congress last year considered — but ultimately did not pass — legislation that would have overhauled prior authorization in Medicare Advantage. And the Biden administration issued rules to make insurers streamline requests to cover treatments.
Several insurers have announced their own plans to scale back their prior authorization requirements over the past couple of years.
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Specific services that will require prior authorization are skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy. There is genuine concern about the costs of some of these items and services. A recent New York Times article highlighted pricey medical products, including paper-thin bandages made of dried bits of placenta, for Medicare patients. The Biden administration had approved a plan to limit Medicare's coverage of the bandages, known as skin substitutes, which were reportedly being sold for roughly $10,000 per square inch. An updated Medicare policy proposes setting a significantly lower payment rate. The new prior authorization program 'is focused on reducing wasteful spending, which is an important goal for Medicare,' Jeffrey Marr, a health economist at the Brown University School of Public Health, told Yahoo Finance. 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'Prior authorization processes and requirements, including the use of artificial intelligence to review requests, may result in administrative hassles for providers, delays for patients in receiving necessary care, and in some instances, denials of medically necessary services, such as post-acute care,' according to Jeannie Fuglesten Biniek, co-author of the KFF report. To allay that fear, CMS noted in the announcement: 'While technology will support the review process, final decisions that a request for one of the selected services does not meet Medicare coverage requirements will be made by licensed clinicians, not machines.' The prior authorization program will not alter Medicare coverage or payment rules, for now, but other services may be added later. There has been pushback. 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