Understanding why prior authorization is a checkpoint for care and coverage

UnitedHealthcare is taking steps to make the prior authorization process faster, simpler and more transparent by:

• Signing on to 6 commitments to streamline, standardize and modernize the process across the industry, including reducing the number of services subject to prior authorization, accelerating response times, improving transparency and expanding real-time, electronic processes
• Introducing a first-of-its-kind national Gold Card Program, which recognizes eligible physicians with a strong track record of evidence-based care by exempting them from certain requirements

Our work includes a continued focus on ways to improve, including: 

• Ongoing efforts to regularly review and reduce the number of services requiring prior authorization
• Advancing technology to speed up the process, reduce administrative burden and costs 
• Increasing transparency throughout the claims process 
• Reducing administrative problems that could impact approval 
• Speeding up turnaround times 

Together, these efforts reflect our commitment to improving the experience for physicians and patients, while supporting safe, appropriate and affordable care. We know there is more work to do, and we will continue to pursue a process that better serves the people and providers who rely on it.

Prior authorization is a clinical review process that helps check whether the treatment being requested — like a complex surgery or a therapy provided as part of a clinical trial — is covered by the patients’ health insurance plan, and that they meet the standards for quality and safety. The process also works to reduce and remove waste. Prior authorization only applies to planned services and is never required for emergencies or urgent care.

It’s a team effort to help ensure care is safe, appropriate and covered. As such, there are a number of decision-makers involved in the prior authorization process:

• Plan sponsors, like employers and federal and state governments, make decisions about what health benefits are offered, including coverage policies that may require prior authorization. 
• Providers evaluate a patient’s condition, recommend treatment and submit prior authorization requests with clinical information supporting the appropriateness of the service. 
• Insurance companies review requests and the members’ benefit plan to check whether the proposed care is covered, and licensed clinicians review requests using evidence-based guidelines (standards that verify that medical treatments have been shown to be safe and effective) to check whether the proposed care is appropriate. 
• Patients (members) work with their providers to understand recommended treatments and make informed decisions about their care.

Together, each part of this team helps balance timely access to care with quality, safety and affordability.

Prior authorizations are mostly used in 3 situations:

1. A condition with multiple treatment options – For example, a condition may require treatment that is available in an outpatient facility or in a hospital.
2. When care guidelines evolve – For example, new clinical evidence may inform and update recommendations on the appropriate use of imaging, such as CT scans and MRIs.
3. When there could be high costs for the patient – For example, a procedure may be very expensive, and prior authorization can help prevent surprise medical costs.

UnitedHealthcare relies on the most current clinical data, medical society guidelines and other resources to evaluate treatments for patient safety, quality and cost. As such, we review medical literature and make updates to our policies regularly.

More than 98.1% of the time, prior authorizations aren’t needed or are quickly approved. Of the 2% of claims that require prior authorization, 91.7% are approved.¹⁰

There are a few reasons why a request wouldn’t be approved. For example, approvals may be based on an administrative, not clinical, issue, such as:

• The request was sent to the wrong insurance company
• It was sent with missing information
• The patient’s benefit amount has reached its limit
• The patient’s plan doesn’t cover the service requested

In some cases, the reason could be something such as: 

• The physician who reviewed the request determined that the treatment doesn’t align with widely accepted medical standards
• The requested service might be experimental, unproven or considered ineffective or not medically appropriate for that member’s condition

This review also protects people from surprise bills for a treatment that isn’t right for them or isn’t covered by their health plan.

The information provided is designed to help people understand prior authorization by presenting a clear and consistent view of how the traditional process works across UnitedHealthcare plans. It uses common, easy-to-interpret definitions that reflect how prior authorization decisions are typically reviewed and measured across our medical benefits, so the data is easier to interpret.

This provided information gives an overview of requests that go through the traditional prior authorization process and fit cleanly into the “approved” or “not approved” categories. Some types of requests are not included because they don’t fit within those definitions. For instance, some services go through a different approval process, and some requests are approved partially, but for a different level of services than originally requested.

By contrast, the CMS-required reports follow a broader definition to accommodate the differences between health plans across the country. For example, the CMS reports include all prior authorization requests received by a plan, including those managed through delegated or specialty arrangements. These differences explain why approval rates may vary between the two views. Both sets of data are accurate, but they serve different purposes.