How UnitedHealthcare is transforming the prior authorization process for patients and providers – Business Insider

Checkpoints exist throughout the American health care system. They ensure people receive appropriate care and avoid preventable errors in treatment or diagnoses. While doctors and hospitals manage most of these checkpoints, health insurers also play a role. The most familiar example is prior authorization, a process through which health plans verify a procedure, prescription or other clinical service will be covered by the patient’s health plan before they receive care.
For instance, a doctor treating a patient with severe knee pain might recommend knee replacement surgery, but before it’s approved, the patient’s health insurance plan requires prior authorization to make sure a more conservative treatment option isn’t more appropriate and that the procedure follows the latest medical guidelines.    
According to Dr. Anne Docimo, chief medical officer at UnitedHealthcare, prior authorization is an oft-maligned but necessary part of our health care system. It ensures that the care people receive is safe and covered by their health plan before they undergo a procedure or surgery, reducing the risk of bills coming as a surprise to patients. 
“Prior authorization has been recognized as an opportunity to reduce low-value or wasteful care and make sure care is safe and effective for all our members,” Dr. Docimo said.
For all the noise and swirl around prior authorization, the reality is it’s exceedingly rare and required for fewer than 2% of all paid claims, according to Dr. Docimo. And very few people (less than 2%) see requests denied.*
Docimo said UnitedHealthcare may seek prior authorization in several scenarios. One is when a procedure or medication comes with a high price tag. The purpose of prior authorization in this scenario is to ensure that everyone is clear on what’s covered before treatment begins. That includes members, hospitals and doctors providing care, employers covering care for their employees, federal and state governments that cover care through Medicaid and Medicare Advantage, and insurers.
Another scenario is when a diagnosis presents multiple treatment options that vary in quality, outcomes and cost. For example, many procedures that used to require inpatient stays in hospitals can now take place in outpatient facilities where operating costs are lower, quality outcomes are as good or better than at inpatient facilities, stays are shorter, and risks of hospital-acquired infections are reduced. In addition, some conditions that can be treated with surgery may also be effectively treated with physical therapy, potentially saving the patient hundreds of dollars in out-of-pocket costs.
Docimo said in these cases, UnitedHealthcare relies on the latest clinical literature and evidence-based recommendations from professional medical societies. “Our prior authorization process is a reflection of up-to-date guidelines and is based on how care is delivered across the country,” she said. “We make it open and transparent. All of our guidelines are posted online and are available to everyone. It’s not a surprise.”
A third situation where prior authorization may be required is when generally accepted care pathways have evolved. Docimo cited examples such as new treatment guidelines for chronic conditions, FDA approvals for existing drugs to address new conditions, or updated recommendations on the appropriate use of imaging, such as X-rays and CT scans.
“Medicine can be complicated,” Docimo said. “When we help providers understand the diagnosis or other information they may need to submit when ordering an image, prior authorization approval rates increase and appeal rates decrease.”
People may be surprised to learn that scenarios where prior authorization often comes into play are relatively rare. Last year, only 26% of the provider groups UnitedHealthcare works with submitted more than one prior authorization request, Docimo said. “It may be perceived as prevalent, but it’s not required in the vast majority of cases,” she said.
Nonetheless, UnitedHealthcare recognizes doctors and health plan members alike are asking for streamlined prior authorization requirements, so the company is taking steps to modernize the process. One significant measure is eliminating the requirements for nearly 20% of UnitedHealthcare’s prior authorization volume, particularly in cases where there was minimal variation in care across the more than 7,000 hospitals in UnitedHealthcare’s network. “For these Current Procedural Terminology codes, providers were generally sticking to the standard of care, and so prior authorization was no longer providing the intended benefit,” Docimo said.
Additionally, UnitedHealthcare has introduced a first-of-its-kind national Gold Card Program, which exempts eligible provider groups from prior authorization requirements for many procedures. Groups of doctors need to submit at least 10 eligible prior authorization requests each year for two consecutive years and achieve at least a 92% approval rate. The program recognizes provider groups who consistently adhere to evidence-based care guidelines.
Finally, the company is investing in meaningfully advancing capabilities that simplify and streamline the consumer and provider experience in this area, including increasing the use of electronic submission of prior authorization requests, which enables a much faster response to the provider.
As these initiatives progress, patients and providers alike can expect a smoother, more efficient and more transparent experience that brings the focus where it belongs: delivering the high-quality care patients deserve.
Learn more about how UnitedHealthcare is striving for safe and effective care.
This post was created by Insider Studios with UnitedHealthcare.
*Applies to members enrolled in UnitedHealthcare fully insured commercial, Medicare Advantage and Medicaid plans.
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