Prior authorization — by which a affected person wants approval from the well being plan earlier than continuing with a medical service — has lengthy created a rift between payers and suppliers. It has gotten such a nasty rap that earlier this 12 months, American Medical Affiliation President Jesse Ehrenfeld implied that prior authorization has overtaken the EHR because the primary ache level amongst physicians.
Suppliers typically blame the method for delays in affected person care, whereas payers counter that it’s a obligatory examine on waste and promotes affected person security.
Payer rationale however, Cigna took a step Thursday that can probably be acquired properly by suppliers complaining of administrative burden — it introduced it has eliminated 25% of medical providers from prior authorization necessities. This represents greater than 600 codes, and consists of 100 surgical codes, practically 200 genetic testing codes, sturdy medical tools, orthoses and prosthetics, and different providers, stated Dr. Scott Josephs, chief medical officer of Cigna Healthcare.
“This effort is a direct results of listening attentively to our clinician companions. We’ll proceed to carry ourselves accountable for enhancing the care expertise and sit up for constructing on this momentum sooner or later,” Josephs stated in an e mail.
The transfer impacts plans throughout Cigna’s U.S. business enterprise and Inexpensive Care Act Market. These plans cowl 16.5 million folks (the insurer has greater than 19 million members in complete). Since 2020, the insurer has eliminated 1,100 medical providers from prior authorization necessities, the announcement famous.
When requested how Cigna selects which providers to take away from prior authorization necessities, Josephs stated the group “repeatedly [reviews] providers, gadgets, and their related codes to find out if prior authorization remains to be obligatory, if the medical proof has advanced, or if eradicating the authorization would enhance wholesome fairness and entry to care.”
A latest KFF evaluation on prior authorization denials amongst Medicare Benefit plans discovered that Cigna denied 8% of prior authorization requests. About 19% of these prior authorization denials had been appealed, and 80% of the denials that had been appealed had been finally overturned.
“We proceed to search for alternatives to streamline prior authorizations, and also will take away practically 500 codes from prior authorization for our Medicare Benefit plans later this 12 months,” Josephs stated in response to this knowledge.
Cigna isn’t the one insurer slicing again on its prior authorization necessities. UnitedHealthcare lately introduced that it’s eliminating 20% of its prior authorization quantity throughout its Medicare Benefit, business, Medicaid and particular person plans beginning September 1. Final 12 months, Aetna introduced that it’s not requiring prior authorization for cataract surgical procedure. This 12 months, it eliminated the prior authorization requirement for bodily remedy in Delaware, New Jersey, New York, Pennsylvania and West Virginia. Humana additionally eradicated prior authorization for cataract surgical procedure for Medicare Benefit members in Georgia.
There are additionally authorized efforts to enhance prior authorization: practically 90 prior authorization reform payments have been thought of this legislative session throughout 30 states, in line with the American Medical Affiliation. The Facilities for Medicare and Medicaid Companies (CMS) additionally proposed a rule that might require some payers to have an automatic course of for prior authorizations, shorten the prior authorization decision-making time and enhance transparency.
Photograph: Piotrekswat, Getty Pictures
