How 3 big insurers are trying to reduce Prior Authorization delays

Three major health insurers have announced plans to reduce the number of medical services that require prior authorization, a practice that often delays patient care and burdens physicians.

Blue Cross Blue Shield of Michigan

The insurer said it will reduce prior authorization requirements by 20%. It also said it will expand its “gold card” program, which will exempt some physicians from the third-party prior authorization approval process, based on their track record of making appropriate prior authorization requests.

UnitedHealthcare

The insurer said it will eliminate prior authorization for many procedure codes, aiming to cut requirements plan-wide by 20%. The codes include those for UnitedHealthcare Medicare Advantage, commercial, Oxford and Individual Exchange plans. The elimination covers major procedures across various specialties, such as gastroenterology and spinal care.

Cigna Healthcare

The insurer said it will remove nearly 25% of medical services from prior authorization requirements, cutting more than 600 codes. The insurer said it has removed more than 1,100 medical services since 2020, with the intent to simplify healthcare for customers and clinicians. The insurer also said it will remove 500 additional codes for Medicare Advantage plans later this year.

Common Eligibility Criteria for BCBS, UnitedHealthcare, and Cigna Healthcare:

• Have a current, non-restricted license to practice medicine in the same state as the furnishing physician.
• Have been a BCBS/UnitedHealthcare/Cigna Healthcare provider for at least one year.
• Have a prior authorization approval rate of at least 90% across all procedure codes in the prior year.
• Be in good standing with the insurer, with no current or recent disciplinary actions.
• Be part of a physician group that has been invited to participate in the Gold Card Program.

In addition to the above eligibility criteria, all three insurers may have additional requirements for participating in the Gold Card Program. For example, some insurers may require providers to participate in certain quality improvement programs or to use certain electronic health record systems.

Note: The Gold Card Program is currently voluntary for all three insurers.