The nation’s major health insurers are promising to scale back and improve a widely despised practice that leads to care delays and complications.
UnitedHealthcare, CVS Health’s Aetna and dozens of other insurers say they plan to reduce the scope of health care claims subject to prior authorization, standardize parts of the process and expand responses done in real time.
Prior authorization means insurers require approval before they’ll cover medical care, a prescription or a service like an imaging exam. Insurers say they do this to guard against care overuse and to make sure patients get the right treatment.
But doctors say the practice has grown in scope and complication, leading to frequent care delays. The fatal shooting of UnitedHealthcare CEO Brian Thompson in December prompted many people to vent their frustrations with coverage issues like prior authorization.
Major health insurers have promised to overhaul the paperwork-laden process before, but little has changed.
Dr. Mehmet Oz, who now oversees the Centers for Medicare and Medicaid Services, said on Monday that insurers are motivated to make something stick this time around.
“There’s violence in the streets over this,” Oz said during a news conference Monday, hours after meeting with most major U.S. insurers. “Americans are upset about it.”
Insurers said Monday that they will standardize electronic prior authorization by the end of next year to help speed up the process. They will reduce the scope of claims subject to medical prior authorization, and they will honor the preapprovals of a previous insurer for a window of time after someone switches plans.
They also plan to expand the number of real-time responses, and they say they will ensure that claims denied for clinical reasons will continue to get reviews by “medical professionals.” But they made no promises that those reviewers will be in the same specialty as the treating doctor, a common complaint from physicians.
Insurers have promised to voluntarily make the changes, but Oz said that the Trump administration will look into regulations if progress isn’t made.
“You fix it or we’re going to fix it,” Oz said.
Researchers say prior authorization has grown more common as care costs have climbed, especially for prescription drugs, lab testing, physical therapy and imaging exams.
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