In Line With AAFP Advocacy, UHC to Reform Prior Authorizations
Changes to Include Eliminating One in Five Current PAs
April 4, 2023, Cindy Borgmeyer — The AAFP’s longstanding advocacy with the nation’s largest private payers yielded encouraging results last week, when UnitedHealthcare announced it will introduce a number of prior authorization reforms across its commercial, Medicare Advantage and Medicaid plans beginning later this year.
The first step will be to eliminate nearly 20% of its current PAs starting this summer. A national gold-carding program and process improvements intended to ease the burden on patients and physicians are also on UHC’s road map.
The PA code eliminations, which will impact most of the company’s commercial, MA and Medicaid businesses, are scheduled to begin in the third quarter of this year and continue through the end of 2023. The process of removing current PAs will be conducted in compliance with state and federal requirements and in accordance with existing commercial health plan agreements, the insurer noted.
“It is encouraging to see that UHC is taking these steps to address one of the most administratively burdensome issues we face as family physicians,” said Stacey Bartell, M.D., AAFP medical director for career and practice. “Eliminating unnecessary PAs allows us to place our focus where it should be — on our patients.”
Early next year, UHC plans to launch a national gold card program designed to allow care delivery groups that meet eligibility requirements to forgo prior authorization requirements for most procedures. Qualifying groups would follow a simple notification process in such instances rather than complete the arduous PA process. The AAFP is actively engaged with UHC to better understand the eligibility requirements and what they mean for family physicians.
Notably, medications are not included in the services for which PAs will initially be eliminated, so in the short term, the impact on family physicians may not be significant. However, that would likely change if the program were expanded to encompass medications and other services family physicians commonly provide. UHC explicitly noted in its March 29 announcement that it “… will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure.”
In recent conversations with UHC leaders about this topic, in fact, the AAFP underscored the significance of including medications in gold card programs in recognition of the broad spectrum of care family physicians deliver.
Overall, the insurer’s actions are in keeping with the Academy’s repeated calls — to Congress, HHS and the Office of the National Coordinator for Health IT, and CMS, among others — to reduce the overall volume of PAs, increase transparency of PA requirements and streamline PA processes.
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For example, the AAFP clearly stated this message in a Feb. 13 letter to HHS Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure. Sent in response to CMS’ proposed rule outlining changes to MA and Medicare Part D for 2024, the letter called on the agency to “finalize proposals to improve equitable, timely access to care by improving MA coverage criteria, increasing transparency of prior authorization and medical necessity determinations, and preventing inappropriate coverage denials by MA organizations.”
Over the next few years, UHC promises more modifications to enhance the PA experience for health care professionals through improved automation and faster decision-making. These changes, according to the insurer, will align with the most recent CMS guidance.
“The AAFP is pleased that UHC recognizes the significant excess burden and cost PAs place on our members and is taking steps to change that,” said Karen Johnson, Ph.D., vice president of the AAFP Division of Practice Advancement. “However, when family physicians frequently contract with 10 or more different plans, the actions of one plan are unlikely to produce measurable impact for our members, as UHC noted in its announcement.
“We call on all plans to take steps to eliminate the unnecessary burdens their actions place on physicians and patients and look forward to working with them to assist family physicians as these changes occur.”