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Prior authorization has remained a significant source of administrative burden, physicians say
by
Jennifer Henderson, Enterprise & Investigative Writer, MedPage Today
September 5, 2024
Physicians frequently cite prior authorization requirements as a significant source of administrative burden. Now, UnitedHealthcare, one of the largest U.S. insurance companies, says it will launch a national “Gold Card” program in an effort to improve the process.
The program — set to launch October 1 — is part of the company’s efforts to “modernize the prior authorization process and simplify the healthcare experience for consumers and providers,” a spokesperson for UnitedHealthcare said in an email.
“Provider groups don’t need to apply to be part of the UnitedHealthcare Gold Card program,” the spokesperson added. “Qualification is awarded if eligibility criteria are met.”
Specifically, provider groups must be in network for at least one UnitedHealthcare plan; Gold Card status will apply across commercial, Individual Exchange, Medicare Advantage, and Medicaid plans, according to the company.
Additionally, provider groups must meet a minimum annual volume of at least 10 eligible prior authorizations each year for 2 consecutive years across eligible codes, and have a prior authorization approval rate of 92% or more across all eligible codes for each of the review years, the company noted.
Currently, a little more than 500 eligible current procedural terminology (CPT) codes for medical services are listed online by the company, with a note that eligible codes may be added or eliminated in the future based on the latest clinical evidence. In total, there are more than 11,000 CPT codes, according to the American Medical Association (AMA).
Ultimately, the expectation is that Gold Card provider groups will see a reduction in their total prior authorization request volume, according to UnitedHealthcare.
For instance, rather than the prior authorization process, provider groups will follow a notification process for eligible procedure codes that will confirm eligibility and network status, but will not require clinical information, the company said.
The move by UnitedHealthcare comes amid a bevy of efforts — at the state and federal level — aimed at limiting prior authorization delays and helping physicians with the burdensome process. The company did not specifically comment on whether such efforts factored into the decision to launch its Gold Card program, though it did note that the program will be effective in all states and modified, when needed, to meet state requirements.
The company “will apply the state criteria first, as required, for the applicable line of business, and then the UnitedHealthcare Gold Card program will take effect for qualifying care provider groups and codes where it does not conflict with state requirements,” it stated.
In 2021, the state of Texas made waves when a law to exempt certain physicians from prior authorization requirements first took effect.
Then in 2023, nine states and the District of Columbia passed legislation that reformed the prior authorization process in their jurisdictions, the AMA said.
And in January, a final rule from CMS setting time limits and other requirements related to prior authorizations drew generally positive reviews from healthcare organizations. However, some groups did express concerns.
A 2022 report from America’s Health Insurance Plans (AHIP) detailing survey responses from 26 plans that cover 122 million commercial enrollees stated that prior authorization programs were evidence-based, that the vast majority of plans were streamlining their prior authorization process, and that a majority of plans reported negative impacts of state regulation of prior authorization programs.
The report also noted more frequent use of gold carding by plans in 2022 than in 2019, jumping from 9% to 21% for prescription medications, and from 32% to 58% for medical services. However, Gold Card programs received mixed reviews from plans in a number of areas, such as reducing administrative burden, being easily implemented, and maintaining or improving patient safety.
AHIP did not immediately respond to a request for comment on UnitedHealthcare’s new Gold Card program.
As for the AMA, its 2023 prior authorization survey of 1,000 physicians (400 primary care and 600 specialists) indicated that the process “continues to have a devastating effect on patient outcomes, physician burnout, and employee productivity,” according to the organization.
For instance, nearly one in four physicians reported that prior authorization has led to a serious adverse event for a patient in their care, and more than one in four physicians reported that prior authorizations are often or always denied. Survey results also suggested physicians and their staff spend 12 hours each week completing prior authorizations.
“Several national insurers announced plans to voluntarily reduce the number of services that require prior authorization in 2023,” the AMA further stated of its survey results. “However, despite these claims and the commitments made [in a previously issued consensus statement on improving the process], physicians report consistently high prior authorization burdens across major health plans.”
The AMA declined to comment on UnitedHealthcare’s Gold Card program until the organization knows more about it.
UnitedHealthcare said last year that, in an effort to reduce the administrative burden on healthcare professionals and their staff, the company would begin an effort to eliminate prior authorization requirements for certain procedure codes that accounted for nearly 20% of the company’s prior authorization volume.
However, the company has also held that prior authorization “plays an important role in reducing costs and improving quality.”
Nevertheless, the company said that its new Gold Card program will help to streamline the process, and that it will continue to be evaluated to add more improvements.
Jennifer Henderson joined MedPage Today as an enterprise and investigative writer in Jan. 2021. She has covered the healthcare industry in NYC, life sciences and the business of law, among other areas.
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