Prior authorization — by which a affected person wants approval from the well being plan earlier than continuing with a medical service — has lengthy created a rift between payers and suppliers. It has gotten such a foul rap that earlier this 12 months, American Medical Affiliation President Jesse Ehrenfeld implied that prior authorization has overtaken the EHR because the no. 1 ache level amongst physicians.
Suppliers typically accuse the method for inflicting delays in affected person care, whereas payers counter that it’s wanted to be a test on waste and promote affected person security.
Payer rationale not withstanding, Cigna took a step Thursday that can possible be obtained properly by suppliers complaining of administrative burden. It introduced Thursday that it eliminated 25% of medical companies from prior authorization necessities. This represents greater than 600 codes, and consists of 100 surgical codes, almost 200 genetic testing codes, sturdy medical tools, orthoses and prosthetics and different companies, stated Dr. Scott Josephs, chief medical officer of Cigna Healthcare.
“This effort is a direct results of listening attentively to our clinician companions. We’ll proceed to carry ourselves accountable for bettering the care expertise and look ahead to constructing on this momentum sooner or later,” Josephs stated in an electronic mail.
The transfer impacts plans throughout Cigna’s U.S. industrial enterprise and Reasonably priced Care Act Market. These plans cowl 16.5 million folks (the insurer has greater than 19 million members in complete). Since 2020, the insurer has eliminated 1,100 medical companies from prior authorization necessities, the announcement famous.
When requested how Cigna selects which companies to take away from prior authorization necessities, Josephs stated the group “constantly [reviews] companies, units, and their related codes to find out if prior authorization remains to be needed, if the scientific proof has advanced, or if eradicating the authorization would enhance wholesome fairness and entry to care.”
A latest KFF evaluation on prior authorization denials amongst Medicare Benefit plans discovered that Cigna denied 8% of prior authorization requests. About 19% of these prior authorization denials have been appealed, and 80% of the denials that have been appealed have been ultimately overturned.
“We proceed to search for alternatives to streamline prior authorizations, and also will take away almost 500 codes from prior authorization for our Medicare Benefit plans later this 12 months,” Josephs stated in response to this information.
Cigna isn’t the one insurer reducing again on its prior authorization necessities. UnitedHealthcare lately introduced that it’s eliminating 20% of its prior authorization quantity throughout its Medicare Benefit, industrial, Medicaid and particular person plans beginning September 1. Final 12 months, Aetna introduced that it’s now not requiring prior authorization for cataract surgical procedure. This 12 months, it eliminated the prior authorization requirement for bodily remedy in Delaware, New Jersey, New York, Pennsylvania and West Virginia. Humana additionally eradicated prior authorization for cataract surgical procedure for Medicare Benefit members in Georgia.
There are additionally authorized efforts to enhance prior authorization: almost 90 prior authorization reform payments have been thought of this legislative session throughout 30 states, in accordance with the American Medical Affiliation. The Facilities for Medicare and Medicaid Providers (CMS) additionally proposed a rule that will require some payers to have an automatic course of for prior authorizations, shorten the prior authorization decision-making time and enhance transparency.
Picture: Piotrekswat, Getty Pictures
