UnitedHealthcare reducing some 'prior authorization' requirements

UnitedHealthcare says it is dialing back some requirements for "prior authorizations" where the Minnetonka-based health insurer calls on doctors and patients to seek advance approval for certain treatments.

The Wall Street Journal first reported the move Wednesday in a story noting that other national insurers also are reducing prior authorizations, which health plans commonly use to check if non-emergency services and prescriptions are clinically appropriate.

The prior authorization process has created so much frustration, the Journal reports, that some state and federal regulators have made overtures of regulatory reform. Insurers, in turn, are now making small adjustments to their requirements.

"Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members," said Dr. Anne Docimo, chief medical officer at UnitedHealthcare, in a statement. "We need to continue to make sure the system works better for everyone, and we will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure."

UnitedHealthcare, which is the health benefits business at Minnetonka-based UnitedHealth Group, said its effort will begin this summer across most of its commercial, Medicare Advantage and Medicaid businesses.

In early 2024, the insurer plans to implement a "Gold Card" program that cuts prior authorization requirements for health care providers that meet certain eligibility requirements. These provider groups will follow a simple notification process, UnitedHealthcare says, for most procedure codes rather than the prior authorization process.

The insurer said it has a range of initiatives over the next several years to improve automation and faster decision-making with prior authorizations. UnitedHealthcare said the federal Centers for Medicare and Medicaid Services has been pushing for such improvements across the industry.

In April 2022, the Office of the Inspector General at the U.S. Department of Health and Human Services reviewed a random sample of prior authorization requests handled by Medicare Advantage plans and found that about 13% of denials actually met coverage rules — meaning they likely would have been paid for under original Medicare.