Context:

Major health insurers in the United States, including UnitedHealthcare and CVS Health's Aetna, have announced plans to improve the process of prior authorization to address widespread complaints about care delays and administrative complications. Prior authorization is a practice where insurers require approval before covering medical care, prescriptions, or services, which they argue helps prevent overuse and ensures appropriate treatment. However, medical professionals criticize the practice for causing frequent delays and administrative burdens, which can negatively impact patient care. In response to these concerns, insurers have committed to reducing the scope of claims requiring prior authorization, standardizing the process, and increasing the number of real-time responses. This move is seen as a positive step towards easing the administrative burden on healthcare providers and improving patient care access, although challenges remain due to the varying policies and forms used by different insurers.

Dive Deeper:

• Health insurers, including UnitedHealthcare and CVS Health's Aetna, have promised to scale back prior authorization practices, which have been criticized for causing delays and complications in patient care. This practice requires insurer approval before covering certain medical services and is intended to prevent overuse and ensure appropriate treatment.

• Medical professionals argue that the expansion of prior authorization has led to significant care delays, increased administrative costs, and negative impacts on patient health, as decisions can take time and patients may experience anxiety or worsening conditions during the wait.

• In response to mounting criticism, insurers have pledged to standardize electronic prior authorization processes by the end of the next year, aiming to streamline the system and reduce the number of claims subjected to this practice.

• Research indicates that prior authorization has become more prevalent as healthcare costs have risen, particularly affecting services like prescription drugs, lab tests, and imaging exams. The practice is especially common in Medicare Advantage plans, where nearly all customers require prior authorization for some services.

• Doctors emphasize the importance of timely access to medical imaging, such as MRIs, for determining treatment effectiveness, particularly in fields like oncology. Delays in obtaining these images due to prior authorization issues can lead to treatment setbacks and increased patient anxiety.

• Insurers have committed to expanding real-time responses and conducting medical reviews for denied requests to improve the efficiency and fairness of the authorization process.

• Variability in prior authorization forms and policies among different insurers adds complexity and frustration for healthcare providers, though recent promises of standardization are seen as an encouraging step forward in addressing these challenges.