Nearly seven months after the fatal shooting of an insurance CEO in New York drew widespread attention to health insurers\u2019 practice of denying or delaying doctor-ordered care, the largest U.S. insurers agreed Monday to streamline their often cumbersome preapproval system.<\/p>\n
Dozens of insurance companies, including Cigna, Aetna, Humana, and UnitedHealthcare, agreed to several measures, which include making fewer medical procedures subject to prior authorization and speeding up the review process. Insurers also pledged to use clear language when communicating with patients and promised that medical professionals would review coverage denials.<\/p>\n
While Trump administration officials applauded the insurance industry for its willingness to change, they acknowledged limitations of the agreement.<\/p>\n
\u201cThe pledge is not a mandate,\u201d Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a news conference. \u201cThis is an opportunity for the industry to show itself.\u201d<\/p>\n
Oz said he wants insurers to eliminate preapprovals for knee arthroscopy, a common, minimally invasive procedure to diagnose and treat knee problems. Chris Klomp, director of the Center for Medicare at CMS, recommended prior authorization be eliminated for vaginal deliveries, colonoscopies, and cataract surgeries, among other procedures. Health insurers said the changes would benefit most Americans, including those with commercial or private coverage, Medicare Advantage, and Medicaid managed care.<\/p>\n
The insurers have also agreed that patients who switch insurance plans may continue receiving treatment or other health care services for 90 days without facing immediate prior authorization requirements imposed by their new insurer.<\/p>\n
But health policy analysts say prior authorization \u2014 a system that forces some people to delay care or abandon treatment \u2014 may continue to pose serious health consequences for affected patients. That said, many people may not notice a difference, even if insurers follow through on their new commitments.<\/p>\n
\u201cSo much of the prior authorization process is behind the black box,\u201d said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.<\/p>\n
Often, she said, patients aren\u2019t even aware that they\u2019re subject to prior authorization requirements until they face a denial.<\/p>\n
\u201cI\u2019m not sure how this changes that,\u201d Pestaina said.<\/p>\n
The pledge from insurers<\/a> follows the killing of UnitedHealthcare CEO Brian Thompson, who was shot in midtown Manhattan in early December on the way to an investor meeting, forcing the issue of prior authorization to the forefront.<\/p>\n Oz acknowledged \u201cviolence in the streets\u201d prompted Monday\u2019s announcement. Klomp told KFF Health News that insurers were reacting to the shooting because the problem has \u201creached a fever pitch.\u201d Health insurance CEOs now move with security details wherever they go, Klomp said.<\/p>\n \u201cThere\u2019s no question that health insurers have a reputation problem,\u201d said Robert Hartwig, an insurance expert and a clinical associate professor at the University of South Carolina.<\/p>\n The pledge shows that insurers are hoping to stave off \u201cmore draconian\u201d legislation or regulation in the future, Hartwig said.<\/p>\n But government interventions to improve prior authorization will be used \u201cif we\u2019re forced to use them,\u201d Oz said during the news conference.<\/p>\n \u201cThe administration has made it clear we\u2019re not going to tolerate it anymore,\u201d he said. \u201cSo either you fix it or we\u2019re going to fix it.\u201d<\/p>\n Here are the key takeaways for consumers:<\/p>\n 1. Prior authorization isn\u2019t going anywhere.<\/strong><\/p>\n Health insurers will still be allowed to deny doctor-recommended care, which is arguably the biggest criticism<\/a> that patients and providers level against insurance companies. And it isn\u2019t clear how the new commitments will protect the sickest patients, such as those diagnosed with cancer, who need the most expensive treatment.<\/p>\n 2. Reform efforts aren\u2019t new.<\/strong><\/p>\n Most states have already passed at least one law<\/a> imposing requirements on insurers, often intended to reduce the time patients spend waiting for answers from their insurance company and to require transparency from insurers about which prescriptions and procedures require preapproval. Some states have also enacted \u201cgold card\u201d programs for doctors that allow physicians with a robust record of prior authorization approvals to bypass the requirements.<\/p>\n Nationally, rules proposed by the first Trump administration and finalized by the Biden administration<\/a> are already set to take effect next year. They will require insurers to respond to requests within seven days or 72 hours, depending on their urgency, and to process prior authorization requests electronically, instead of by phone or fax, among other changes. Those rules apply only to certain categories of insurance, including Medicare Advantage and Medicaid.<\/p>\n Beyond that, some insurance companies committed to improvement long before Monday\u2019s announcement. Earlier this year, UnitedHealthcare pledged to reduce prior authorization volume by 10%. Cigna announced its own set of improvements in February.<\/p>\n 3. Insurance companies are already supposed to be doing some of these things.<\/strong><\/p>\n For example, the Affordable Care Act already requires insurers to communicate with patients in plain language about health plan benefits and coverage.<\/p>\n But denial letters remain confusing because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term \u201cnon-approved requests\u201d in Monday\u2019s announcement.<\/p>\n Insurers also pledged that medical professionals would continue to review prior authorization denials. AHIP claims this is \u201ca standard already in place.\u201d But recent lawsuits allege otherwise, accusing companies of denying claims in a matter of seconds.<\/p>\n 4. Health insurers will increasingly rely on artificial intelligence.<\/strong><\/p>\n Health insurers issue millions of denials every year, though most prior authorization requests are quickly, sometimes even instantly, approved.<\/p>\n The use of AI in making prior authorization decisions isn\u2019t new \u2014 and it will probably continue to ramp up, with insurers pledging Monday to issue 80% of prior authorization decisions \u201cin real-time\u201d by 2027.<\/p>\n \u201cArtificial intelligence should help this tremendously,\u201d Rep. Gregory Murphy (R-N.C.), a physician, said during the news conference.<\/p>\n \u201cBut remember, artificial intelligence is only as good as what you put into it,\u201d he added.<\/p>\n Results from a survey published by the American Medical Association in February indicated 61% of physicians are concerned that the use of AI by insurance companies is already increasing denials.<\/p>\n 5. Key details remain up in the air.<\/strong><\/p>\n Oz said CMS will post a full list of participating insurers this summer, while other details will become public by January.<\/p>\n He said insurers have agreed to post data about their use of prior authorization on a public dashboard, but it isn\u2019t clear when that platform will be unveiled. The same holds true for \u201cperformance targets\u201d that Oz spoke of during the news conference. He did not name specific targets, indicate how they will be made public, or specify how the government would enforce them.<\/p>\n While the AMA, which represents doctors, applauded the announcement, \u201cpatients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions,\u201d the association\u2019s president, Bobby Mukkamala, said in a statement. He noted that health insurers made \u201cpast promises\u201d to improve prior authorization in 2018.<\/p>\n Meanwhile, it also remains unclear what services insurers will ultimately agree to release from prior authorization requirements.<\/p>\n Patient advocates are in the process of identifying \u201clow-value codes,\u201d Oz said, that should not require preapproval, but it is unknown when those codes will be made public or when insurers will agree to release them from prior authorization rules.<\/p>\n Do you have an experience with prior authorization you\u2019d like to share? <\/em>Click here<\/em><\/a> to tell your story.<\/em><\/p>\n\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n