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Academic researchers have looked at how commercial health insurers handle advance reviews of proposed treatment plans and winced.
Aya Zaari Jabri, a management science specialist at Stanford, and colleagues analyzed 2024 commercial plan provider directories from Humana, CVS Health's Aetna subsidiary and UnitedHealth's UnitedHealthcare subsidiary. The researchers found each insurer had a completely different strategy for conducting prior authorization reviews.
Humana has pulled out of the market for employer-sponsored health plans, but UnitedHealthcare and Aetna are still big employer plan players.
The three insurers subjected a total of 4,645 procedures to prior authorization reviews.
Only 638 procedures were subject to reviews by all three insurers. That implied that two insurers got by without asking doctors to justify performing 4,007 of the procedures.
UnitedHealthcare, for example, reviewed 2,247 medical and surgical services at least some of the time. Aetna put only 573 services on its review list.
UnitedHealthcare reviewers tended to look at more criteria when assessing the requests for coverage.
"These large differences are unexplained and need to be scrutinized," the researchers write in their paper.
The backdrop: Physicians have complained about prior authorization review processes for years.
A year ago, the Centers for Medicare & Medicaid Services persuaded all big U.S. health insurers to join in a voluntary effort to streamline and improve prior authorization review processes.
Only 33% of the physicians who participated in a recent American Medical Association survey said they thought the CMS effort would make a meaningful difference for physicians.
Employers and benefits advisors may empathize with physicians and worry about the impact of prior authorization-related administrative burdens on patient care.
But employers and benefits advisors may also worry about the impact of eliminating prior authorization reviews on the cost of care: Analysts at Milliman, an actuarial consulting firm, have predicted that eliminating prior authorization reviews could lead to 3.3% increase in premiums at an employer plan with a narrowly focused prior authorization review program and as much as 4.8% at an employer plan with a broad prior authorization review program.
The researchers' views: The Jabri team's findings suggest that CMS efforts to streamline and improve prior authorization reviews may be disappointing.
Insurers have pledged to reduce the number of services subject to reviews and shift to standard electronic review systems, but "there is no planned standardization across insurers to eliminate the fragmentation in the processes," the researchers write.
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