UnitedHealth Group reduces use of prior authorization process by 20%

Photo: Courtesy of UnitedHealthcare

Ahead of a final rule that would limit the amount of time insurers have to approve prior authorization requests and would require an electronic, FHIR API standard, UnitedHealth Group on Wednesday said it would reduce the use of its prior authorization process by 20% for some nonurgent surgeries and procedures.

Starting this summer, hospitals and physicians will get coverage approval for certain non-emergency procedures when UnitedHealthcare begins procedure code reductions, which will eliminate nearly 20% of current prior authorizations.

The procedure code reductions will continue through the rest of the year for most commercial, Medicare Advantage and Medicaid businesses. Prior authorization removal will comply with state and federal requirements, and will be done in accordance with existing commercial health plan agreements, UHG said.

Also, in early 2024, the company will implement a national Gold Card Program for providers that meets eligibility requirements, eliminating prior authorizations for most procedures. Having a gold card exempts physicians from prior authorization requirements.

The Gold Card status applies for most UnitedHealthcare members across UnitedHealthcare's businesses -- commercial, Medicare Advantage and Medicaid. Qualifying provider groups will follow a simple notification process for most procedure codes, rather than the prior authorization process.

"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 of UnitedHealthcare. "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. We hope other health plans will make similar changes."

WHY THIS MATTERS

UnitedHealthcare will deploy a range of initiatives over the next several years – aligned with the most recent guidance from the Centers for Medicare and Medicaid Services – creating an enhanced prior authorization experience through improved automation and faster decision-making, UHG said.

This is part of a comprehensive effort to simplify the healthcare experience for consumers and providers, UnitedHealth Group said.

But it is also in line with a CMS proposed rule to streamline the prior authorization process, which physicians have said causes administrative burden and care delays for patients.

Cigna and Aetna are also making moves to revamp the prior authorization process, according to The Wall Street Journal.

THE LARGER TREND

In December 2022, CMS released the Advancing Interoperability and Improving Prior Authorization Proposed Rule, which would require implementation of a Health Level 7 (HL7) FHIR standard APIs to support electronic prior authorization. 

Certain payers would need to include a specific reason when denying requests, publicly report certain prior authorization metrics and send decisions within 72 hours to seven days, depending on the level of urgency, which is twice as fast as the existing Medicare Advantage response time limit, CMS said. 

The provisions would be implemented starting on January 1, 2026, though provider groups MGMA and WEDI have told CMS they'd like to see them begin before that date.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org

Margie Zuk and Melissa "Penny" Chase will offer more detail at the HIMSS23 session "Preparing for the Next Cyber Attack." It is scheduled for Wednesday, April 19 at 10:15 a.m. - 10:35 a.m. CT at the North Building, Level 3, in Hall B, Booth 8539, Federal Health Pavilion.