10 prior authorization updates to know in 2023

Several payers, including UnitedHealthcare and Cigna, announced prior authorization cuts in 2023. Here is more on that and other prior authorization updates Becker's reported this year:

1. Prior authorization is the most burdensome regulatory issue facing medical groups, with 89% saying it is very or extremely burdensome, according to a Nov. 13 report from the Medical Group Management Association.

2. CMS on Nov. 6 proposed new health equity changes for prior authorization policies and procedures at Medicare Advantage organizations to better determine any disproportionate impact on underserved populations that may delay or deny access to services. The health equity changes would be effective in contract year 2025 and are part of a broader proposed rule from CMS. Comments on the proposal are due by Jan. 5, 2024.

3. Blue Cross Blue Shield of Massachusetts announced Nov. 6 it is removing 14,000 prior authorization requirements for home care services for its 2.6 million commercial members beginning Jan. 1, 2024. The new policy will be effective for Medicare Advantage members in 2025.

4. Blue Cross Blue Shield of Michigan announced Sept. 7 it is cutting approximately 20 percent of its prior authorization requirements and expanding its gold-card program. James Grant, MD, the payer's senior vice president and chief medical officer, told Becker's the changes are part of an evolving process. 

5. Cigna said Aug. 24 it removed prior authorization requirements for more than 600 medical procedures, cutting the number of prior authorizations it requires by 25 percent. 

6. UnitedHealthcare cut 20 percent of its prior authorizations across two waves, the first on Sept. 1 and the second on Nov. 1. The payer first announced March 29 that it would be eliminating 20 percent of its current prior authorization requirements and said it could implement a national gold care program in 2024. 

7. On average, Medicaid managed care organizations denied around 1 in 8 prior authorization requests, according to a July 17 audit from the HHS' Office of Inspector General. Of the 115 MCOs the OIG audited, 12 had prior authorization denial rates greater than 25 percent. 

8. UnitedHealthcare backed off a plan to implement a gastroenterology endoscopy prior authorization policy that was set to take effect June 1 and instead set up an advance notification process for non-screening GI procedures.   

9. CMS issued a final rule April 5 that, among other things, aims to streamline Medicare Advantage and Part D prior authorizations and clamp down on misleading marketing practices. The rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary. 

10. Texas' physician gold-card rule took effect in October 2022, but providers are not seeing the results they hoped for, the American Medical Association reported March 1.

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