Insurers Make Changes to Prior Approvals Ahead of Rulemaking

After the Centers for Medicare and Medicaid Services proposed new rules aimed at streamlining the prior approval process for most health plans in the U.S., a number of the country’s largest insurers announced their own steps to improve the process.

UnitedHealthcare announced in late March that it would cut the use of prior authorizations by 20% for some non-urgent surgeries and procedures. Starting in the third quarter of 2023, the insurer will remove many procedures and medical devices from its list of services that require prior approval, and continue through the rest of the year for most commercial, Medicare Advantage and Medicaid plans.

Meanwhile, insurance giant Cigna said it has been in the process of reducing the prior authorization for about 500 services and devices. And Aetna is working to automate and simplify prior authorizations.

Market experts expect other insurers to follow suit as frustration over the long wait times and horror stories of patients dying while waiting for approval mount. The bad press and resulting lawsuits, in conjunction with the new rule making is likely to prompt more health insurers to revamp their prior authorization procedures.

The proposed rule

The rule is aimed at tackling one of the biggest headaches for patients and practitioners alike. Waiting for prior authorizations for care, pharmaceuticals or medical devices can lead to delays in care and increased risk of hospitalization from those delays.

The goal of the proposed rule, which would take effect in 2026, is to reduce the bureaucracy around prior authorizations and cut wait times for responses that some providers say sometimes take weeks to get approved.

The specifics of the rule are as follows:

  • Insurers would be required to render a decision within seven days after a request for a non-urgent service or item (compared to the current 14 days).
  • If the requested care or item is urgent, the insurer must render a decision within 72 hours.
  • If the insurer denies the request, it must include a specific reason for doing so.
  • Most group and individual health plans, Medicare Advantage, Medicaid managed care and state Medicaid agencies would be required to build and maintain a system for electronically approving prior authorizations, known as a “fast health care interoperability resources application programming interface.”
  • The interface must be able to ascertain whether a prior authorization request is required and “facilitate the exchange of prior authorization requests and decisions” from the provider’s electronic health records or practice management system.

Recent & Related

The Risk Report – February 2024

The Risk Report – February 2024

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