The Prior Authorization Universe: Pulling Providers into a Different Dimension

We move and operate in a three-dimensional world—with width, length and height as our major reference points.  You can throw time in there as a fourth dimension.  Recently, however, a few physicists have theorized that there could be multiple dimensions beyond these four, allowing for interdimensional travel, time slips and whole range of exotic possibilities.  Then there’s the concept of the multiverse and the Many-Worlds theory.  It’s enough to get one’s head spinning. 

 Medical providers are generally individuals with their feet planted firmly on the ground.  But, in recent times, they may have come to feel they are living in an alternate reality; and it’s all because of a growing trend among health plans to require doctors to obtain permission from the payer before a surgery can proceed.  For example, Cigna has been expanding its prior authorization requirements in recent years, particularly for high-cost imaging and surgical procedures.  Providers can expect other payers, such as Aetna, Anthem, BCBS, Medicare and UnitedHealthcare (UHC), to impose preauthorization requirements, as well. 

 So what is the current universe of prior authorizations?  Which procedures are subject to it?  How long does it take to get approval?  How does this affect the average anesthesia practice? And are there any signs that these requirements are being reduced? 

 Why This Matters 

We all know the arguments for and against prior authorizations.  The insurance plans believe they are critical to ensuring the establishment of medical necessity prior to the procedure, meaning there should be less denials on the back end.  Physicians and other practitioners argue that this amounts to insurance companies practicing medicine and that clinicians should be the ones to determine and carry out the appropriate treatment plan for a patient without having to first get permission from the payer. 

Why is this important to specialties such as anesthesia?  After all, anesthesia services are typically included under the surgeon’s approval.  In other words, the anesthesia team generally does not have to obtain its own prior authorization.  However, if the surgeon schedules and performs a procedure without first getting prior approval—where such approval is required by the patient’s health insurance—or in some way failed to follow the exact preauthorization protocol of the payer in question (e.g., submission timetables, submission methodology, etc.), both the surgeon’s payment and the anesthesia provider’s reimbursement relative to that procedure will likely be denied.   

 The Triggering Events 

While there is a wide variance of requirements when it comes to prior authorizations within the insurance industry, there are some common procedures or circumstances that often fall under the prior approval rubric.  Depending on the payer, providers can expect to see prior authorization requirements in the following situations: 

• Advanced imaging 

• Outpatient surgery 

• Specialty medications  

• Cardiac procedures 

• Inpatient admissions (generally or limited to elective procedures, based on the payer) 

The typical turnaround time from submission of the request to approval is two to five business days for non-urgent procedures and 24 to 48 hours for urgent requests.  (You can expect Cigna to take a bit longer.)  Providers should also remember that each payer has unique requirements regarding the submission of a request for approval, such as whether to use a portal, phone or fax. 

So, enduring the prior authorization process is a fact of life that providers have come to expect, though it still leaves many in the medical community frustrated and frazzled.  But it’s not all bad news. 

Signs of Easing 

We recently reported that the Centers for Medicare & Medicaid Services (CMS) has implemented measures to streamline the prior authorization process relative to its Medicare Advantage program.  In addition, Anthem has recently expanded their list of procedures that are now exempt from the preauthorization process.  Several state BCBS plans have adopted gold card programs, meaning providers with historically high approval rates can earn exemptions from the prior approval process.  

Perhaps the biggest sign that payers could be in the process of easing their prior authorization requirements came in the form of a recent announcement by UnitedHealthcare (UHC).  On its website, the insurance giant stated that it would begin rolling back the prior authorization requirements for certain services.  In a September communication, UHC affirmed that, effective October 1, they would be eliminating 30% of prior authorization requirements for the following products: 

• UnitedHealthcare commercial plans 

• UnitedHealthcare Medicare Advantage plans 

• UnitedHealthcare Community plans 

• UnitedHealthcare Individual Exchange plans 

• UnitedHealthcare Oxford plans 

The specific items being removed from UHC’s preauthorization list can be viewed by accessing their Prior Authorization and Notification Tool. 

The payer cited the following reason for the change: 

Removing these prior authorization requirements is part of our effort to help reduce administrative work, remove barriers that can delay care and give you more time to focus on patient care.

If only every other carrier could come to the same conclusion.  It would appear, then, that providers’ concerns are being seriously considered, at least by some in the insurance industry.  Payers are aware of the difficulty prior authorizations place on doctors and other clinicians who simply want to take care of their patient’s needs.  UHC’s own statement acknowledges that this red tape approach delays treatment and encroaches on providers’ time.  It’s good to see that at least some payers are taking real steps to make life a little easier for those providing the care.