Major health insurers in the U.S., including UnitedHealthcare and CVS Health’s Aetna, are committing to revise the controversial practice of prior authorization, which has been widely criticized for causing delays in patient care. This reform aims to streamline the claims process and alleviate administrative burdens on healthcare providers.
Prior authorization requires medical professionals to obtain approval from insurance companies before administering treatments, prescribing medications, or conducting certain tests, such as imaging exams. Although insurers argue that this practice is necessary to prevent overuse of services and ensure appropriate care, the increasing complexity of the process has led to significant delays in treatment. Recent incidents, including the tragic shooting of UnitedHealthcare’s CEO Brian Thompson, have intensified public outrage over such coverage issues.
To address these concerns, insurers announced plans to standardize electronic prior authorization processes by the end of the following year. They intend to streamline the claims that require prior authorization and allow for the preapprovals of previous insurers to remain valid for a limited period when patients switch plans. Additionally, insurers are working to enhance the number of real-time responses for prior authorizations and expedite reviews for denied requests.
Research indicates that the prevalence of prior authorization has grown alongside rising healthcare costs, particularly for essential services such as prescription medications, laboratory tests, physical therapy, and imaging studies. Dr. Ashley Sumrall, an oncologist from Charlotte, North Carolina, highlighted the detrimental effects of these delays, particularly regarding routine exams essential for tracking treatment progress. Such waiting periods can lead to unnecessary anxiety for patients who seek timely updates on their health status.
In a positive development, the movement toward standardization in prior authorization practices signifies a potential turning point, as it may reduce discrepancies among insurers and improve access to care. Dr. Sumrall noted that “any step in the direction of standardization is encouraging,” and such initiatives promise to benefit patients navigating complex healthcare systems.
Insurers assert that these improvements will affect a wide range of insurance plans, including employer-sponsored coverage, individual market options, Medicare Advantage, and Medicaid programs. This broad commitment could pave the way for a more efficient healthcare experience, ultimately ensuring that patients receive the care they need without unnecessary delays.