UnitedHealthcare Begins Eliminating Prior Authorization Requirements Across Their Major Plans

On September 1st, 2023, UnitedHealthcare completed its first phase as part of a two-phase approach to eliminate prior authorization requirements for various procedures and services across their commercial, Medicare, and Medicaid plans [1].

The second phase occurred on November 1st, 2023, eliminating additional requirements across their community plan [1]. Prior authorization is a process through which healthcare providers obtain coverage approval from health plans before performing specific procedures or care services [2]. Prior authorizations are essential to ensure a service or prescription is being utilized in a clinically appropriate setting [3]. However, they can cause significant amounts of administrative burden on healthcare professionals and their staff, as well as limit access to patients if coverage is denied. To help reduce this healthcare burden, UnitedHealthcare has begun eliminating prior authorizations for many procedures and services, including radiology services and genetic testing, across their major healthcare plans, which will account for nearly 20% of their overall prior authorization volume [1].

UnitedHealthcare Begins Eliminating Prior Authorization Requirements Across Their Major Plans: Article by Paige Stitzel, Windrose Consulting Group

Prior authorizations can significantly impact physicians' daily functioning and treatment decisions for their patients, as they can spend a significant amount of time away from patient care [4]. This results in an increased use of healthcare resources, including potentially ineffective treatment usage or additional office visits that significantly contribute to healthcare costs [4]. In addition, patients experience delays in care, which can negatively impact patient clinical outcomes. However, prior authorizations are critical to ensure patient safety and proper procedure/treatment usage. According to UnitedHealthcare, one of the crucial prior authorization requirements that will be eliminated is a cardiology stress test for Medicare Advantage members, which attests to nearly 316,000 prior authorization requests per year [3]. By removing this requirement, UnitedHealthcare hopes to allow patients to have earlier access to treatments / earlier diagnoses without physicians having to wait for coverage approval. However, this could also cause improper treatment usage, in which physicians are prescribing medicines to patients who are not considered suitable, thus leading to adverse patient safety outcomes and resulting in an overall increase in healthcare costs. In addition to UnitedHealthcare, other major plans, including Cigna and Aetna, have announced plans to reduce the number of prior authorization requirements across their major plans [3]. While the move to eliminate prior authorization requirements is viewed advantageously amongst physicians and patients, concerns remain on whether these changes will negatively impact the healthcare system by increasing costs due to improper treatment usage and implications on patient safety.

While reducing the requirements for prior authorizations can help streamline care delivery and reduce the burden on physicians and patients, prior authorizations remain critical for health plans to ensure clinical quality, safety, and healthcare waste and abuse. The goal of UnitedHealthcare and other major plans to eliminate a significant volume of their prior authorization requirements may have tremendous implications on the healthcare system, which may experience an increase in patient-reported adverse events or overall costs. However, one aspect health plans should consider is that the type of prior authorization can significantly impact the physician's administrative burden. For example, a prior authorization which requires evidence of patients' medical documentation has a more significant burden than a prior authorization that requires physician attestation, which is usually a box for the physician to check, confirming that the patient meets the treatment/procedure requirements. While eliminating the prior authorization requirements for specific procedures/services removes the administrative burden for physicians, changing the prior authorization type can also help reduce these burdens without eliminating a critical step, ensuring proper treatment usage/patient safety. Prior authorizations function as an essential safety mechanism in our healthcare system. While they can cause administrative burdens for physicians and delays in patient care, they prevent improper treatment usage and help to ensure patient safety. Therefore, instead of eliminating their requirements, plans may consider simplifying their prior authorization procedures, which will help reduce the administrative burden and ensure these protective measures are in place.