Dreaded Medical Paperwork Required by Health Insurers to Be Trimmed

The insurer also said it would eliminate, starting next year, many prior-authorization requirements for so-called gold-card doctors and hospitals whose requests it nearly always approves. And it aims to automate and speed up prior authorization, though that will likely take a few years.

“We’re not deaf to the complaints out there,” said Philip Kaufman, chief growth officer at UnitedHealthcare. “We’ve taken a hard look at ourselves and this process.” 

The company is expected to announce the changes on Wednesday.

The steps are a sign that the health-insurance industry is rethinking prior authorization, which has long been a source of frustration among doctors and patients who have said it creates administrative headaches and sometimes delays or blocks access to needed care. 

Prior authorization has generated so much resentment in recent years that some state and federal officials have begun taking steps to ease the process, putting pressure on health insurers to revamp their programs.

As the complaints have increased, health insurers have been making tweaks. 

Cigna

Group, another large insurer, said it was reducing prior authorization, including removing the requirement for about 500 services and devices since 2020. 

Meantime,

CVS Health Corp.’s

Aetna health insurance arm said it was working to automate and simplify prior authorization. 

“Reducing the volume of prior authorization demands and implementing gold-carding programs are both central reforms we have sought,” American Medical Association President Jack Resneck Jr. said.

He said he was cautiously optimistic about UnitedHealthcare’s changes but wants to see the details to confirm they will create meaningful improvements.

Prior authorization is a longtime feature of health insurance. For procedures like knee replacements or expensive arthritis drugs, the companies require doctors to document that a patient really needs the service.

Insurers say prior authorization helps ensure patients get the best and most appropriate care, as well as tamping down unnecessary costs.

“The real intent is to guard clinical quality and patient safety,” said

Margaret-Mary Wilson,

UnitedHealth Group’s chief medical officer. 

For doctors, however, filling out the documentation can be so time-consuming that many practices and hospitals employ staff dedicated to the work.

“It’s extremely frustrating,” said Angus Worthing, a rheumatologist in Washington, D.C., whose practice has to employ roughly one prior-authorization-focused staffer for every two doctors, he said. 

Patients typically wait two to four weeks to get medications under the process, he said, and while they wait, he sometimes needs to put them on other drugs that cause side effects.  

In an AMA survey of 1,001 doctors last year, 94% said prior authorization delayed needed care, while a third said the process led to a serious adverse event for a patient. 

Some doctors and patients also complain that health insurers use the process to deny valid care. The Department of Health and Human Services’ Office of Inspector General reported last year that 13% of prior-authorization denials by privately run Medicare plans were for benefits that should have been covered.

To smooth and limit prior authorization, states including Texas, Michigan and Louisiana have passed new prior-authorization laws with “gold card” provisions in the past few years; about 29 states are currently considering legislation, according to the AMA. 

The Centers for Medicare and Medicaid Services last year issued a proposed rule that would require insurers to automate the process, increase transparency and provide shorter turnaround times. The changes would apply to plans including private insurers’ Medicare and Medicaid products, as well as coverage sold in the federal Affordable Care Act marketplace. 

UnitedHealthcare processes about 13 million prior-authorization requests a year, out of a volume of about 600 million claims, company officials said. They said the company’s changes are projected to reduce the number of prior authorizations to around 10 million annually. 

Under the revamp, the insurer sought to remove prior-authorization requirements for services that are approved at a high rate, where there was no risk posed to patients and where costs are low, company officials said. 

The company didn’t list specific services that will be affected but suggested they could include certain types of medical equipment like orthopedic support devices and some genetic tests used for diagnosis. 

The overall cost impact of pulling back on prior authorization will be very small, Mr. Kaufman said.  

Write to Anna Wilde Mathews at [email protected] and Stephanie Armour at [email protected]

The insurer also said it would eliminate, starting next year, many prior-authorization requirements for so-called gold-card doctors and hospitals whose requests it nearly always approves. And it aims to automate and speed up prior authorization, though that will likely take a few years.

“We’re not deaf to the complaints out there,” said Philip Kaufman, chief growth officer at UnitedHealthcare. “We’ve taken a hard look at ourselves and this process.” 

The company is expected to announce the changes on Wednesday.

The steps are a sign that the health-insurance industry is rethinking prior authorization, which has long been a source of frustration among doctors and patients who have said it creates administrative headaches and sometimes delays or blocks access to needed care. 

Prior authorization has generated so much resentment in recent years that some state and federal officials have begun taking steps to ease the process, putting pressure on health insurers to revamp their programs.

As the complaints have increased, health insurers have been making tweaks. 

Cigna

Group, another large insurer, said it was reducing prior authorization, including removing the requirement for about 500 services and devices since 2020. 

Meantime,

CVS Health Corp.’s

Aetna health insurance arm said it was working to automate and simplify prior authorization. 

“Reducing the volume of prior authorization demands and implementing gold-carding programs are both central reforms we have sought,” American Medical Association President Jack Resneck Jr. said.

He said he was cautiously optimistic about UnitedHealthcare’s changes but wants to see the details to confirm they will create meaningful improvements.

Prior authorization is a longtime feature of health insurance. For procedures like knee replacements or expensive arthritis drugs, the companies require doctors to document that a patient really needs the service.

Insurers say prior authorization helps ensure patients get the best and most appropriate care, as well as tamping down unnecessary costs.

“The real intent is to guard clinical quality and patient safety,” said

Margaret-Mary Wilson,

UnitedHealth Group’s chief medical officer. 

For doctors, however, filling out the documentation can be so time-consuming that many practices and hospitals employ staff dedicated to the work.

“It’s extremely frustrating,” said Angus Worthing, a rheumatologist in Washington, D.C., whose practice has to employ roughly one prior-authorization-focused staffer for every two doctors, he said. 

Patients typically wait two to four weeks to get medications under the process, he said, and while they wait, he sometimes needs to put them on other drugs that cause side effects.  

In an AMA survey of 1,001 doctors last year, 94% said prior authorization delayed needed care, while a third said the process led to a serious adverse event for a patient. 

Some doctors and patients also complain that health insurers use the process to deny valid care. The Department of Health and Human Services’ Office of Inspector General reported last year that 13% of prior-authorization denials by privately run Medicare plans were for benefits that should have been covered.

To smooth and limit prior authorization, states including Texas, Michigan and Louisiana have passed new prior-authorization laws with “gold card” provisions in the past few years; about 29 states are currently considering legislation, according to the AMA. 

The Centers for Medicare and Medicaid Services last year issued a proposed rule that would require insurers to automate the process, increase transparency and provide shorter turnaround times. The changes would apply to plans including private insurers’ Medicare and Medicaid products, as well as coverage sold in the federal Affordable Care Act marketplace. 

UnitedHealthcare processes about 13 million prior-authorization requests a year, out of a volume of about 600 million claims, company officials said. They said the company’s changes are projected to reduce the number of prior authorizations to around 10 million annually. 

Under the revamp, the insurer sought to remove prior-authorization requirements for services that are approved at a high rate, where there was no risk posed to patients and where costs are low, company officials said. 

The company didn’t list specific services that will be affected but suggested they could include certain types of medical equipment like orthopedic support devices and some genetic tests used for diagnosis. 

The overall cost impact of pulling back on prior authorization will be very small, Mr. Kaufman said.  

Write to Anna Wilde Mathews at [email protected] and Stephanie Armour at [email protected]