Easing the prior authorization journey

Prior authorization, or preauthorization, is a process through which health care providers obtain coverage approval from health plans prior to performing certain non-emergency procedures. It can also be an important “checkpoint” to make sure a service or prescription is a clinically appropriate option. However, UnitedHealthcare is working to make sure the system works better for everyone.

What is UnitedHealthcare doing to help ease prior authorizations?

Starting this summer, UnitedHealthcare is eliminating nearly 20% of current prior authorizations, as part of a comprehensive effort to simplify the health care experience for consumers and providers.

These code reductions will begin in the third quarter and continue through the rest of the year for most Commercial, Medicare Advantage and Medicaid businesses. Prior authorization removal will comply with state and federal requirements and will be done in accordance with existing Commercial health plan agreements.

In early 2024, the company also will implement a national Gold Card Program for care provider groups that meet eligibility requirements, eliminating prior authorization requirements for most procedures. The Gold Card status applies for most UnitedHealthcare members across UnitedHealthcare’s businesses — Commercial, Medicare Advantage and Medicaid. Qualifying care provider groups will follow a simple notification process for most procedure codes rather than the prior authorization process.

“Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members,” said Dr. Anne Docimo, chief medical officer of UnitedHealthcare. “We need to continue to make sure the system works better for everyone, and we will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure. We hope other health plans will make similar changes.”

These changes are in addition to efforts currently in place to help ease the prior authorization process. For instance, UnitedHealthcare has introduced a new feature to help consumers track these requests from start to finish through myuhc.com or the UnitedHealthcare mobile app. Through enhanced advocacy models, UnitedHealthcare may also proactively call consumers to help them review their coverage options and discuss alternative treatments.

For care providers, UnitedHealthcare will deploy a range of initiatives over the next several years — aligned with the most recent guidance from the Centers for Medicare & Medicaid Services (CMS) — creating an enhanced prior authorization experience through improved automation and faster decision-making.

These investments in technology and automation are aimed at simplifying the experience when prior authorization is still required and will include integrating more seamlessly into electronic medical records.