How prior authorization is changing and why it matters
By Jarrod Fowler, MHA, FMA Director of Health Care Policy and Innovation
Humana, UnitedHealthcare, and the federal government are making changes affecting prior authorization.
Humana is expanding its use of automated prior authorization to include cardiovascular, surgical, sleep, and imaging services. Prior authorization requirements vary by service. More information is
available here.
Meanwhile, UnitedHealthcare has just launched a so-called
Gold Card Program for prior authorization, which will allow some physicians to forgo submitted prior authorization requests for certain medical, behavioral, and mental health services.
Requirements for entering the Gold Card Program
UnitedHealthcare evaluates all practices defined by a single tax ID number (TIN) to determine whether they meet all the following criteria to qualify for the Gold Card Program:
- In-network participation for at least one line of business representing UnitedHealthcare commercial, UnitedHealthcare® Medicare Advantage, UnitedHealthcare Individual Exchange* and UnitedHealthcare Community plans;
- A minimum annual volume of at least ten eligible prior authorizations across participating lines of business each year for two consecutive years across all Gold Card eligible codes; and
- A prior authorization approval rate of 92% or higher each year for two consecutive years. This rate applies to prior authorization status for Gold Card eligible codes, across all participating lines of business, after all appeals were exhausted.
Practices do not need to apply for Gold Card status. UnitedHealthcare will make each practice’s Gold Card status determination available to them as well as reporting of the practice’s performance as compared to program eligibility criteria. Additional details about program eligibility, requirements, and qualification are
available here.
Finally, the federal government has issued rules to streamline the prior authorization process. The rule requires Medicare Advance, Medicaid, and CHIP plans to make standard prior authorization decisions within seven calendar days and to make expedited decisions within 72 hours. Plans sold on the ACA exchange will have 15 days to respond to standard prior authorization requests and 72 hours to respond to expedited requests. Large employer-sponsored plans are not covered under the rule.
Affected plans also will be required to include specific reasons for denying prior authorization requests, and data will be collected to help evaluate the efficiency of the prior authorization process. It is important to note that these changes are limited to medical services and that drugs are not covered under the rule. Read
KFF’s complete analysis of the federal rule.
Why it matters
For years, the FMA and other advocates for medicine have worked to draw attention to the problems with prior authorization. While many challenges remain, Congress, federal regulatory offices, and insurers appear to recognize that excessive prior authorizations must be reined in.
What’s next
Comprehensive federal legislation is the only option for completely addressing the concerns about prior authorization. H.R. 4822, a piece of legislation that relates to prior authorization under the Medicare Advantage program, would represent a major leap forward. However, building the momentum and the coalitions to address prior authorization through federal legislation could take considerable time – and, as with all legislation, passage is not guaranteed. The FMA will keep you informed as developments occur.