Physicians have long complained about onerous prior authorization requirements, which often delay care and sometimes have catastrophic consequences. Medicine's advocacy for improvements seems to be paying off.
UnitedHealthcare – Texas' second largest health insurer by market share – recently announced it will eliminate prior authorization requirements for certain procedure codes starting Sept. 1 across several of its national plans. The change is expected to reduce overall prior authorization volume by 20% and is part of an effort to “simplify the health care experience” for patients and clinicians, according to an Aug. 1 announcement.
The Texas Medical Association has staunchly and successfully advocated for prior authorization reform at the state and federal levels. The association has carried that message to ongoing meetings with payers, including one on July 17 with United, to resolve physician concerns.
TMA President Rick Snyder, MD, applauds the new policy while lamenting its limited scope.
“It is surprising, but it’s a welcome surprise,” he told Texas Medicine Today. “I hope this opens the door [to United and other payers] get[ting] rid of prior authorization completely, for all codes.”
United will eliminate the prior authorization requirements in two phases, on Sept. 1 and Nov. 1. The payer’s Medicare Advantage, commercial, Oxford, and Individual Exchange plans will see code changes on both dates. Its Community Plan will be updated on Nov. 1 only.
United urges physicians and practices to consult its code removal list for each health plan as “there will be some differences.”
Starting next year, United also will implement a national gold-carding program for eligible clinician groups, with more information forthcoming.
Such programs seemingly draw inspiration from a TMA-backed 2021 Texas law. Since it took effect in October 2022, Texas physicians who earn approvals on at least 90% of prior authorization requests for a given service or medication can earn a “gold card” exempting them from prior authorization requirements for that service or medication.
More recently, TMA secured a form change that allows physicians to bypass the most onerous part of prior authorization requests when renewing an existing prescription. And during the 2023 regular legislative session, lawmakers, with TMA’s full-throated support, restricted insurers from requiring more than one prior authorization request annually for patients with autoimmune and certain blood disorders. TMA also has voiced opposition to a separate United pilot program related to gastrointestinal procedures.
Although payers often attribute prior authorization requirements to concerns about quality and safety, several studies show such requirements in fact often have a negative effect, with the added consequence of contributing to physician burnout. For instance, a 2021 survey by the American Medical Association found 93% of physician respondents reported care delays related to prior authorization.
“The delays that result from prior authorizations diminish quality and safety because people do not get the test or the medical or surgical intervention [they need] in a timely manner,” Dr. Snyder said.
Under the leadership of TMA's Council on Socioeconomics, TMA recently resumed its regular meetings with major Texas payers to discuss prior authorization, gold-carding, and other payment policy issues after the meetings were suspended during the COVID-19 pandemic. In the most recent meeting with United, for instance, TMA also discussed credentialing, education on proper billing, and value-based care.
Continue to read Texas Medicine Today for updates from these payer meetings. For courses on billing, coding and payers, visit TMA’s Education Center.
Emma Freer
Associate Editor
(512) 370-1383