Prior authorization — in which a patient needs approval from the health plan before proceeding with a medical service — has long created a rift between payers and providers. It has gotten such a bad rap that earlier this year, American Medical Association President Jesse Ehrenfeld implied that prior authorization has overtaken the EHR as the number one pain point among physicians.
Providers often blame the process for delays in patient care, while payers counter that it’s a necessary check on waste and promotes patient safety.
Payer rationale notwithstanding, Cigna took a step Thursday that will likely be received well by providers complaining of administrative burden — it announced it has removed 25% of medical services from prior authorization requirements. This represents more than 600 codes, and includes 100 surgical codes, nearly 200 genetic testing codes, durable medical equipment, orthoses and prosthetics, and other services, said Dr. Scott Josephs, chief medical officer of Cigna Healthcare.
“This effort is a direct result of listening attentively to our clinician partners. We will continue to hold ourselves accountable for improving the care experience and look forward to building on this momentum in the future,” Josephs said in an email.
The move affects plans across Cigna’s U.S. commercial business and Affordable Care Act Marketplace. These plans cover 16.5 million people (the insurer has more than 19 million members in total). Since 2020, the insurer has removed 1,100 medical services from prior authorization requirements, the announcement noted.
When asked how Cigna selects which services to remove from prior authorization requirements, Josephs said the organization “continuously [reviews] services, devices, and their associated codes to determine if prior authorization is still necessary, if the clinical evidence has evolved, or if removing the authorization would improve healthy equity and access to care.”
A recent KFF analysis on prior authorization denials among Medicare Advantage plans found that Cigna denied 8% of prior authorization requests. About 19% of those prior authorization denials were appealed, and 80% of the denials that were appealed were eventually overturned.
“We continue to look for opportunities to streamline prior authorizations, and will also remove nearly 500 codes from prior authorization for our Medicare Advantage plans later this year,” Josephs said in response to this data.
Cigna isn’t the only insurer cutting back on its prior authorization requirements. UnitedHealthcare recently announced that it is eliminating 20% of its prior authorization volume across its Medicare Advantage, commercial, Medicaid and individual plans starting September 1. Last year, Aetna announced that it is no longer requiring prior authorization for cataract surgery. This year, it removed the prior authorization requirement for physical therapy in Delaware, New Jersey, New York, Pennsylvania and West Virginia. Humana also eliminated prior authorization for cataract surgery for Medicare Advantage members in Georgia.
There are also legal efforts to improve prior authorization: nearly 90 prior authorization reform bills have been considered this legislative session across 30 states, according to the American Medical Association. The Centers for Medicare and Medicaid Services (CMS) also proposed a rule that would require some payers to have an automated process for prior authorizations, shorten the prior authorization decision-making time and improve transparency.
Photo: Piotrekswat, Getty Images