Kennedy says well being insurers promise to alter prior authorization course of
WASHINGTON — Well being and Human Companies Secretary Robert F. Kennedy Jr. mentioned Monday that the nation’s largest well being insurers have promised to take steps to streamline the often-criticized prior authorization course of, which might delay or deny sufferers’ entry to care.
Prior authorization is a cost-cutting software utilized by well being insurers that requires them to log off on exams, procedures or medicine earlier than sufferers can get them.
The insurance coverage tactic drew renewed consideration final 12 months after the deadly taking pictures of Brian Thompson, the CEO of UnitedHealth’s insurance coverage arm, in New York Metropolis.
Sufferers and medical doctors say prior authorization creates too many roadblocks, forcing folks to attend days or even weeks for wanted remedies or denying them altogether.
About 1 in 6 insured adults say they’ve had prior authorization issues, based on a survey from KFF, a well being coverage analysis group.
Kennedy mentioned quite a lot of giant insurance coverage firms — together with Blue Cross Blue Defend Affiliation, Cigna, Elevance Well being, GuideWell, Humana, Kaiser Permanente and UnitedHealthcare — pledged to make the modifications, which can be carried out throughout personal insurance coverage, Medicare Benefit and Medicaid.
AHIP, a medical health insurance business commerce group, mentioned the modifications may gain advantage 257 million folks in the US.
Consultants pressured, nevertheless, that prior authorization is not going away.
It’s “going to streamline it in some incremental methods solely,” mentioned Dr. Adam Gaffney, a essential care doctor and assistant professor at Harvard Medical College.
Medical insurance firms have made related commitments to repair prior authorization prior to now, a truth Kennedy and Dr. Mehmet Oz, administrator of the Facilities for Medicare & Medicaid Companies (CMS), acknowledged at a media occasion Monday. In 2018 and once more in 2023, medical health insurance firms made commitments to reform prior authorization, Oz mentioned, however many didn’t implement such reforms.
Requested what’s completely different this time, he mentioned, “There’s violence within the streets over these points,” alluding to the taking pictures of Thompson.
AHIP — previously America’s Well being Insurance coverage Plans — detailed the steps medical health insurance firms dedicated to in a information launch earlier Monday.
Beginning subsequent 12 months, if sufferers change insurance policy whereas they’re receiving remedy, their new plans will honor the prevailing prior authorizations for related take care of as much as 90 days. As well as, subsequent 12 months, insurers might want to present easier-to-understand explanations after they deny authorizations and supply steering about attraction.
Insurers have pledged to have medical professionals assessment all authorization denials, although AHIP mentioned that’s one thing that insurers say they already do.
Insurers have additionally dedicated to streamline the prior authorization course of by making it simpler to submit requests on-line by 2027. Not less than 80% of digital requests can be answered in actual time by 2027, AHIP mentioned.
Plans might also scale back the variety of medical providers topic to prior authorizations in sure cities or states — although particular commitments about what that may embody had been missing.
Chris Klomp, who leads the Medicare program at CMS, mentioned the company would love insurers to roll again prior authorization necessities for frequent providers, together with colonoscopies, cataract surgical procedure and childbirth.
Kennedy additionally mentioned CMS is working with insurers to make it simpler to get prior authorization for diagnostic imaging, bodily remedy and outpatient surgical procedure.
Gaffney criticized the pledges, saying insurers have had a long time to alter their practices.
“Discuss is affordable,” Gaffney mentioned. “Extra elementary reform can be wanted to handle the ever-present limitations to care imposed by insurance coverage companies.”
Kaye Pestaina, director of this system on affected person and client safety at KFF, mentioned a few of commitments might have direct impacts on sufferers, reminiscent of honoring current prior authorizations for 3 months after sufferers change insurers.