Exclusive: Insurers align pre-treatment review requirements
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Major health insurers including UnitedHealthcare, Humana and CVS Health/Aetna will adopt a single standard for health providers to request pre-treatment reviews starting next year, the insurers tell Axios.
Why it matters: Health plans often deny or delay coverage because of incomplete documentation.
- A standardized approach could reduce the back-and-forth between plans and providers — and improve the odds of delivering timely care.
Zoom in: The insurers beginning Jan. 1 will align data submission requirements for frequently requested medical services, including orthopedic surgeries, CT scans and MRIs.
- The framework will apply across commercial insurance, Medicare and Medicaid. It's an important step toward immediate electronic prior authorization answers, the insurers said.
- The industry teased a move to standardized requirements last year, when it committed to streamlining the submission process for patients and doctors. Insurers said earlier this month that the commitments have so far led to an 11% decrease in prior authorizations.
By the numbers: More than 50 health insurers representing more than 250 million covered lives have signed on to the agreement so far.
- Others participating in the initiative include several Blue Cross Blue Shield insurers, along with Centene, Kaiser Permanente and Cigna.
What they're saying: "Standardizing what health plans require us to submit makes it far easier for us to streamline and simplify our own efforts to get the right information submitted," Jeff Balser, CEO of Vanderbilt Health, said in a statement.
- "This will significantly increase approvals on the first submission, while expediting the care we believe is needed."
Yes, but: The agreement doesn't cover prescription drugs — often the source of prior authorization fights between health plans and clinicians.
- Medicare earlier this month proposed requiring insurers to speed up pre-treatment drug reviews.
- A staffer with the insurer trade group AHIP said insurers didn't want to get ahead of federal requirements that might be finalized, and that drugs could be added to the standardized framework in the future.
What we're watching: Insurers will know the effort is successful if prior authorization denial rates go down, the AHIP staffer said.
