Prior Authorization

[BALDELMO]

The Insurance companies are starting to feel the pressure to modify their prior authorization hurdles.[EXTERNAL LINK] - WSJ News Exclusive | Dreaded Medical Paperwork Required by Health Insurers to Be Trimmed

 

[somarco]

The (UHC) will cut nearly 20% of its current prior authorizations, according to a new release, in a bid to simplify the process for both providers and its members. UnitedHealth will begin reducing codes in the third quarter, and the efforts will continue through the rest of the year.

UHC said the code reductions will extend to most commercial, Medicare Advantage and Medicaid plans.

Aetna, meanwhile, has put a focus on automation (AI?) for prior authorization, according to the article.

not behind a paywall . . .
https://www.fiercehealthcare.com/payers/unitedhealthcare-begin-reducing-prior-authorizations-summer

Remains to be seen how well this change will work when implemented. Right now I view this as sausage and you may not like what comes out the other end . . .

 

[Yagents]

Great, a computer will determine if your worthy of getting a test or surgery. A new selling point for mapd

 

[Chazm]

Great, a computer will determine if your worthy of getting a test or surgery. A new selling point for mapd

I think I read an article that Cigna has been doing this for a decade. Not just MAPD but their whole dept. obviously not med Supp.
In short, it's easier to have an algorithm determine codes that are lower cost whether to approve or deny a claim.
Because it costs more to approve or deny a claim manually from an actual person. They figure most people will pay a $300 claim than appeal it.

 

[somarco]

it's easier to have an algorithm determine codes that are lower cost whether to approve or deny a claim.

Carriers use computer programs to streamline a lot of their work, including underwriting and claims payment. Matching ICD-10 with CPT-4 codes is robotic and has been used for years to pay or deny a claim that is submitted.

Pre-authorization is a different matter . . . the procedure or treatment has not yet been performed. In other words, it is a POTENTIAL claim, not an actual one.

Spinal laminectomy is often recommended in cases involving stenosis. This is a complicated and expensive procedure that runs $50k and up.

Carriers will delay approval for surgery but will approve less invasive treatment including injections at the site or physical therapy. Anyone who has had a laminectomy will tell you they tried everything to avoid the surgery but when the pain is so great they agree to the surgery . . . which is 90% effective.

It is not uncommon for a carrier to deny or delay approval of an MRI which is definitive and necessary before the surgery can be performed. PA denials for the MRI may become more prevalent towards the end of a calendar/plan year in hope that the insured will change to a different carrier who will have to absorb the cost of the claim.

A PA can often involve a medical review board before approval. Unlike TV shows where hospitals have weekly review meetings, carrrier's may only have quarterly medical reviews

Orthopedic surgery is about quality of life, not life or death. It is simple to talk about corrective procedures when the decision maker is not the one in pain.

PA means a faster decision, which can include a denial. A quick decision is not necessarily the correct one, but rather a decision that satisfies the metrics of CMS guidelines.