Health Insurers Aim to Simplify Coverage Approvals

Big health insurers are taking steps to make it easier for people to get the care they need. UnitedHealthcare, CVS Health's Aetna, and many others are working to cut down on the hassle of prior authorization. This is the process where insurers need to approve medical care, prescriptions, or services before they cover them. Insurers say they do this to control costs and make sure patients get the right treatment. But doctors argue that the process has become too complicated and often leads to delays. The recent shooting of UnitedHealthcare CEO Brian Thompson brought a lot of attention to these issues. Doctors have been vocal about the problems with prior authorization. Dr. Mehmet Oz even called it \"a pox on the system\" during his Senate confirmation hearing. He pointed out that it adds unnecessary administrative costs. Insurers are now promising to make some big changes. They plan to standardize the electronic prior authorization process by the end of next year. This means using the same system across different insurers. They also want to reduce the number of claims that need prior authorization and honor pre-approvals from previous insurers for a certain period after someone switches plans.

Researchers note that prior authorization has become more common as healthcare costs have risen. Michael Anne Kyle, an assistant professor at the University of Pennsylvania, says this puts patients in a tough spot. \"We’re sort of trapped between care being unaffordable and then these non-financial barriers and administrative burdens growing worse, \" she said. Nearly all customers of Medicare Advantage plans need prior authorization for some services. A study by the health policy research organization KFF found that insurers denied about 6% of all requests in 2023. Dr. Ashley Sumrall, an oncologist in Charlotte, North Carolina, has seen an increase in prior authorizations for routine exams like MRIs. She says these images are crucial for determining the effectiveness of treatments and planning next steps. Delays in approval can harm patients by allowing diseases to progress untreated. They can also cause a lot of anxiety for patients. Sumrall points out that different insurers have different forms and policies, which complicates the process. \"For years, the companies have been unwilling to compromise, so I think any step in the direction of standardization is encouraging, \" she said. The insurers say their promises will apply to coverage through work, the individual market, Medicare Advantage plans, and Medicaid.

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