5 Takeaways From Health Insurers’ New Pledge To Improve Prior Authorization

Nearly seven months after the deadly shooting of an insurance CEO in New York drew great attention to the practice of health insurers to deny or delay the care-ordered care, the greatest American insurers agreed on Monday to rationalize their often heavy prior system.

Dozens of insurance companies, including Cigna, Aetna, Humana and United, have agreed to several measures, in particular by doing fewer medical procedures subject to prior authorization and accelerating the examination process. Insurers also undertook to use clear language during communication with patients and have promised that health professionals would examine the refusals of coverage.

While officials of the Trump administration applauded the insurance sector for its desire to change, they recognized the limits of the agreement.

“Commitment is not a mandate,” said Mehmet Oz, director of Centers for Medicare & Medicaid Services, during a press conference. “This is an opportunity for the industry to show up.”

Oz said he wanted insurers to eliminate preapprowes from knee arthroscopy, current and minimal procedure to diagnose and treat knee problems. Chris Klomp, director of the CMS CMIC Center, recommended an earlier authorization for vaginal deliveries, colonoscopies and cataract surgeries, among other procedures. Health insurers have said that changes would benefit most Americans, including those who have commercial or private coverage, a drug advantage and care managed by Medicaid.

Insurers have also agreed that patients who change insurance plans can continue to receive treatment or other health services for 90 days without facing immediate previous authorization requirements imposed by their new insurer.

But analysts of health policies say that prior authorization – a system that requires some people to delay care or abandon treatment – can continue to pose serious health consequences for affected patients. That said, many people may not notice any difference, even if insurers follow their new commitments.

“A large part of the previous authorization process is at the origin of the black box,” said Kaye Pestaina, program director on patient protections and consumers in KFF, a health information non -health body that includes KFF Health News.

Often she said, patients do not even know that they are subject to prior authorization requirements until they are faced with denial.

“I don’t know how it changes it,” said Pestaina.

The commitment of insurers follows the murder of the CEO of Unitedhealthcare, Brian Thompson, who was killed in the Midtown Manhattan in early December on the path of an investor meeting, forcing the question of the authorization prior to the avant-garde.

Oz recognized that “violence in the streets” caused the announcement on Monday. Klump told Kff Health News that insurers reacted to the shooting because the problem had “reached a fever field”. Health Insurance CEOs are now traveling with the details of security wherever they go, Klump said.

“There is no doubt that health insurers have a reputation problem,” said Robert Hartwig, an insurance expert and an associate clinical professor at the University of South Carolina.

The commitment shows that insurers hope to avoid “more draconian” legislation or regulations in the future, Hartwig said.

But government interventions to improve prior authorization will be used “if we are forced to use them,” said Oz at the press conference.

“The administration has clearly indicated that we are not going to tolerate it anymore,” he said. “So, either you repair it, or we will repair it.”

Here are the main dishes to remember for consumers:

1. The prior authorization is not going.

Health insurers will always be allowed to refuse care collected by the doctor, which is undoubtedly the greatest criticism that patients and providers are heading against insurance companies. And it is not clear how new commitments will protect the most sick patients, such as those diagnosed with cancer, who need the most expensive treatment.

2. Reform efforts are not new.

Most States have already adopted at least one imposing law requirements to insurers, often intended to reduce the time that patients spend waiting for their insurance company responses and require the transparency of insurers whose prescriptions and procedures require pre-degation. Some states have also promulgated “gold cards” programs for doctors who allow doctors a solid file for prior authorization to get around the requirements.

Nationally, the rules proposed by the first Trump administration and finalized by the Biden administration should already come into force next year. They will oblige insurers to respond to requests within seven days or 72 hours, depending on their emergency, and to process electronically prior authorization requests, rather than by telephone or by fax, among other modifications. These rules only apply to certain insurance categories, including Medicare Advantage and Medicaid.

Beyond that, some insurance companies have undertaken to improve long before the announcement on Monday. Earlier this year, United Healthcare is committed to reducing the volume of prior authorization by 10%. Cigna announced her own improvement set in February.

3. Insurance companies are already supposed to do some of these things.

For example, the affordable care law already obliges insurers to communicate with patients in clear language on the advantages and coverage of health regimes.

But denial letters remain confusing because companies tend to use jargon. For example, AHIP, the commercial group of the Health Insurance Industry, used the term “not approved requests” in the announcement on Monday.

Insurers have also promised that health professionals would continue to examine the prior refusals of the authorization. AHIP claims that it is “a standard already in place”. But recent proceedings allege the opposite, accusing companies of refusing complaints in a few seconds.

4. Health insurers will count more and more on artificial intelligence.

Health insurers issue millions of refusals each year, although most of the previous authorization requests are quickly approved, sometimes even instantly approved.

The use of the AI ​​to make previous authorization decisions is not new – and it will probably continue to get up, insurers committing on Monday to issue 80% of the previous authorization decisions “in real time” by 2027.

“Artificial intelligence should help this a lot,” said representative Gregory Murphy (RN.C.), a doctor at the press conference.

“But remember, artificial intelligence is as good as what you put there,” he added.

The results of a survey published by the American Medical Association in February indicated that 61% of doctors fear that the use of AI by insurance companies already increases.

5. Key details remain in the air.

Oz said CMS will publish a full list of participating insurers this summer, while other details will become public by January.

He said insurers have agreed to publish data on their use of prior authorization on a public dashboard, but it is not clear when this platform is unveiled. The same goes for the “performance targets” that Oz spoke at the press conference. He did not appoint specific objectives, indicated how they will be made public or specify how the government would apply them.

While the AMA, which represents the doctors, applauded the announcement, “patients and doctors will need details demonstrating that the last insurer commitment will provide substantial actions,” said association president, Bobby Mukkamala, in a statement. He noted that health insurers had made “past promises” to improve prior authorization in 2018.

Meanwhile, it is also not clear what insurers will finally accept to release previous authorization requirements.

Patient defenders are identifying the “low value codes,” said Oz, who should not require pre-approval, but we do not know when these codes are made public or when insurers agree to release them from previous authorization rules.

Do you have experience with the prior authorization you would like to share? Click here To tell your story.