Prior authorizations, one of health insurers’ many “utilization management” techniques, is a hot topic amongst practicing physicians, patients, and regulators, to name a few. The prior-authorization process requires a health insurer to consent to a doctor’s proposed course of treatment for a patient before the insurer agrees to pay for any medical services the physician wishes to provide. The insurer’s consent is allegedly based on whether the prescribed treatment plan is considered “medically necessary” by the insurer.
Insurers argue that this prospective review for medical necessity limits unnecessary medical services and payments. Physicians, on the other hand, argue that this process impedes patients’ access to necessary care, endeavors to supplant the expertise of the treating physician, and costs the health care industry more money due to higher administrative costs in complying with the prior-authorization requirements. In April 2023, CMS addressed the prior authorization process in a final rule 4201-F, which limits Medicare Advantage plans to require only one prior authorization per course of treatment.
Recently, UnitedHealthcare, one of the largest health insurers in the United States, announced that it would be implementing a new policy with respect to the prior authorization process. The policy required 26.7 million of its members to obtain prior authorizations before the insured could obtain an endoscopy or colonoscopy procedure, both of which are used to detect digestive system diseases, such as Crohn’s and Ulcerative Colitis. Furthermore, the procedures are also used to monitor disease progress after a diagnosis has been made.
Due to pressure from physician societies, on the date that the new policy was to begin, UnitedHealthcare pivoted and changed its approach to endoscopy and colonoscopy services. The insurer announced that, rather than requiring prior authorizations for non-screening gastroenterology procedures, it would implement a process called “Advance Notification,” which is intended to “collect more data on which providers should be eligible for [its] previously announced 2024 Gold Card[1] administrative simplification program.” Separately, UnitedHealthcare has indicated that beginning in the third quarter of 2023, it will eliminate prior authorization requirements for certain codes that make up approximately 20% of its current prior authorization volume.
The debate between physicians and insurers regarding the topic of prior authorization does not appear that it will be settled any time soon, despite insurers’ insistence that they are reforming the process. Instead, it seems we will merely see changes to the form of the hurdles that physicians and their patients are expected to cross.
[1] Gold Carding is a practice where “payers waive prior authorization on services and prescription drugs ordered by providers with a proven track record of prior authorization approvals.” According to the American Medical Association, approximately 29 states are considering prior authorization legislation which contains “gold card” provisions.[1] In Texas, such a law has been in effect since 2021
