Health Insurers Commit to Enhancing Coverage Review Processes to Reduce Delays and Complaints

Major health insurance providers in the United States are undertaking initiatives to reform their coverage review procedures, which have historically caused delays in care and widespread dissatisfaction among patients and healthcare providers. Insurers such as UnitedHealthcare, CVS Health's Aetna, along with several others, have announced plans to narrow the scope of claims requiring prior authorization, standardize the review process, and increase the use of real-time response mechanisms.

Prior authorization is a prerequisite in which insurers must approve specific medical services, prescriptions, or procedures like imaging examinations before coverage is granted. While intended to prevent overuse of healthcare resources and ensure appropriate treatment, this practice has expanded considerably, often creating bottlenecks and administrative burdens. Healthcare professionals have flagged the growth of prior authorization requirements as a significant contributor to care delays.

The decision to streamline and regulate these processes follows heightened public and professional frustration, especially in light of incidents such as the December shooting death of UnitedHealthcare CEO Brian Thompson, which highlighted issues within the insurance landscape. Medical experts, including Dr. Mehmet Oz, have criticized prior authorization as an overcomplicated barrier that inflates administrative costs and hampers patient care.

In the coming months, insurers plan to implement electronic prior authorization systems to expedite approvals, reduce the number of claims subject to review, and recognize preapprovals from different insurers within specified timeframes. Additionally, they aim to provide more immediate responses and conduct thorough reviews for denied claims to improve transparency and efficiency.

Research indicates that the prevalence of prior authorization has surged alongside rising healthcare costs, particularly affecting areas like prescription drugs, diagnostic testing, physical therapy, and imaging. The policy implementations aim to mitigate these issues, but concerns persist about their impact on timely patient care.

Experts such as Michael Anne Kyle from the University of Pennsylvania emphasize the need to balance access to affordable care with administrative procedures. A 2023 study by KFF found that nearly all Medicare Advantage plan users encounter prior authorization, with approximately 6% of requests being denied. Healthcare providers, including oncologists like Dr. Ashley Sumrall, report increased barriers for essential diagnostic procedures, which can delay treatment and cause patient anxiety, a phenomenon often referred to as 'scanxiety.'

Overall, these reforms are intended to make coverage review processes more transparent, standardized, and patient-friendly across multiple insurance programs, including employer-based, individual, Medicare Advantage, and Medicaid plans.