9 Prior Authorization updates physicians should know

Prior authorization is a common and controversial practice in healthcare, affecting physicians and patients alike. Becker’s has covered some of the latest developments and opinions on prior authorization in 2023. Here are some of the highlights:

Prior authorization statistics

• According to a survey by the American Medical Association, 94% of physicians reported that prior authorization led to delays in patient care and increased administrative burden.
• The same survey found that 39% of physicians spent one to nine hours on prior authorizations weekly in 2022.

Prior authorization actions by health systems and insurers

• Eight major U.S. health systems have canceled their Medicare Advantage (MA) contracts so far in 2023, often citing low reimbursement rates and prior authorization hassles.
• Humana has rolled back a prior authorization requirement for cataract surgery for MA beneficiaries in Georgia.
• Cigna Healthcare has removed nearly 25% of medical services from prior authorization requirements, cutting more than 600 codes.
• Blue Cross Blue Shield of Michigan announced a new effort to reduce prior authorization requirements by 20% to improve healthcare quality and access while reducing administrative tasks.
• UnitedHealthcare started a two-phased approach to eliminate prior authorization requirements for several procedure codes, aiming to cut prior authorization criteria by 20%.

Prior authorization legislation by states

• California legislature is considering a bill that would prohibit prior authorization for any healthcare service if the plan or insurer approved — or would have approved — not less than 90% of the prior authorization requests a provider submitted in the most recent completed one-year contracted period.
• Michigan launched new prior authorization rules in June in an effort to make the process faster, more effective and more transparent.

Prior authorization opinions by physicians

• Barbara Jung, MD, President of the American Gastroenterological Association: “Prior authorization has become increasingly utilized by insurers who provide no rationale or data to justify its implementation. This often results in serious health care access issues and adverse patient outcomes due to significant delays or outright denial of care. Instead of getting timely treatment, many patients have told us that the stress of fighting their own insurance company exacerbates their conditions.”
• Benjamin Levy, MD, Gastroenterologist with University of Chicago Medicine: “Many gastroenterologists are concerned about prior authorization and advanced notification processes causing delays in cancer diagnosis for patients with alarm symptoms and medical management in general. As a physician community, we breathed a sigh of relief when the proposed new prior authorization requirements for (UnitedHealthcare) were changed to advanced notification.”