Insurers pledge to reduce prior authorization burden

According to MedCity News, prior authorization has historically been a point of contention between payers and providers. Although health insurers argue that prior authorization reduces costs and ensures patients get appropriate care, providers say that the process increases administrative burden and can lead to care delays.

In a recent survey from the American Medical Association (AMA), 93% of providers said prior authorization delays access to necessary care, and 89% said it increases physician burnout. In addition, over 80% of providers said issues with prior authorization have led patients to abandon treatment, and 29% said they believed prior authorization requirements led to serious adverse patient outcomes, such as hospitalization.

In the initiative, the organizations pledged to:

• Standardize the electronic prior authorization process
• Reduce the number of medical services requiring prior authorization
• Honor any existing authorizations when patients change health plans during treatment
• Increase transparency and communication around authorization decisions and appeals
• Minimize delays with real-time responses to prior authorization requests
• Ensure medical professionals review non-approved requests

For example, some current and pending CMS regulations apply new limits to the prior authorization process, including ones finalized by the Biden administration in January 2024. CMS and AHIP are also planning to create a public dashboard to track insurers' compliance with their promises in the initiative.

"You fix it or we're going to fix it," Oz said.

Reaction

Although providers and other healthcare organizations have expressed approval of the initiative, many are skeptical the promised changes will come to fruition since health insurers have made similar commitments in the past.

In 2018, AHIP, Blue Cross Blue Shield Association, the American Hospital Association, and other major provider groups issued a "consensus statement" on how to make prior authorization less burdensome. However, surveys from medical groups suggest that prior authorization issues have only worsened since then.

"They not only show growth in the frustration but nobody was moving the dial on the health plan side in adopting at least the sentiment around these consensus agreements," said Anders Gilberg, SVP of government affairs at the Medical Group Management Association, which was part of the 2018 pledge. "Nor did it necessarily give us a sense that they were doing it other than for, more or less, PR purposes at the time because we just never saw anything get done."

Chip Kahn, CEO of the Federation of American Hospitals, said that while the new pledge is encouraging, "the proof is in the pudding" as to whether it will improve patient access to care.

Similarly, AMA said it is "optimistic" about the pledge, but plans to keep an eye on whether insurers will deliver changes to prior authorization and help patients.

According to Noreen Fleming, a nurse and senior director at Optum Advisory*, "the commitment payers announced today to streamline the prior authorization process via reduced requirements, faster decision response times, and increased automation of approvals is a step in the right direction, but the impact of these changes remains unknown. Since each payer will independently define how they will implement these changes, there will remain a high degree of variation in prior authorization requirements and processes that providers will still have to manage."

"In addition, several of the changes proposed are dependent on providers fully embracing electronic prior authorization which remains a challenge," Fleming added.

"[P]atients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions to bring immediate and meaningful changes, break down unnecessary roadblocks, and keep medical decisions between patients and physicians," said AMA president Bobby Mukkamala.

Separately, Soumi Saha, SVP of government affairs at Premier, said that while a voluntary pledge could go a long way, it will still be important for the government to intervene in certain areas.

"There is no level of accountability here," Saha said. "A lot of it is self-governed. So what we would love to see is some guardrails continue to be put into place by CMS and Congress to ensure this does get put into place and it’s truly in the best interest of patients and providers."

*Advisory Board is a subsidiary of Optum, a division of UnitedHealth Group, the parent company of UnitedHealthcare. All Advisory Board research, expert perspectives, and recommendations remain independent.