Across three major commercial insurers, only 14% of procedure codes that triggered a prior authorization requirement at one insurer triggered it at all three, according to a study published May 19 in the Annals of Internal Medicine.
The study examined publicly available provider manuals from Aetna, Humana and UnitedHealthcare. Researchers used ChatGPT to read each manual for each code to determine whether prior auth would be required and what the specific criteria for it would be. They then built a searchable Python database and validated results by manually comparing the number of identified codes against services listed in each corresponding provider manual.
The authors noted the study was limited to the three payers and doesn’t account for external utilization management vendors, which could further complicate the process.
Four notes:
1. Of the 4,645 codes requiring prior auth from at least one of the three insurers, all three required it for 638 codes (14%), two required it for 949 codes (20%), and only one required it for 3,058 codes (66%).
2. The criteria insurers use to determine whether prior auth is necessary differ greatly. For medical and surgical services, Aetna relies on the combination of services being provided. UnitedHealthcare applies that criterion, along with state, age, diagnosis, purchase cost of durable medical equipment, and site of care. Across all codes, none of the three insurers used the same criteria to require prior auth or the same requirements to obtain it.
3. At the time of the study, Humana required prior auth for 2,660 medical and surgical services, compared with 2,247 for UnitedHealthcare and 573 for Aetna. Humana used site of care to determine whether prior auth was required for 9 medical and surgical services, while UnitedHealthcare used it for 1,039. Aetna required a site-of-service review to obtain prior auth for more than 200 services, compared with 11 for Humana and 33 for UnitedHealthcare.
4. The researchers found no standardization across insurers to eliminate fragmentation in the prior auth process, even as insurers have pledged to adopt electronic prior auth submissions and reduce requirements overall. They wrote that the large differences in prior auth volume are “unexplained and need to be scrutinized.” The findings align with prior Medicare Advantage research showing that 4,044 Part B clinical services required prior auth from at least one of five large MA insurers, with only 5.9% required by all.
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