Dive Brief:
- UnitedHealthcare is nixing prior authorization for roughly 1,700 medical codes starting in October, amid growing public pressure to remove administrative speedbumps to patients accessing care.
- The insurance giant sent a memo to providers on Tuesday disclosing the codes, which it said amounted to roughly 30% of its preapproval requirements for its commercial, Medicare Advantage, Medicaid and Affordable Care Act plans.
- The codes span a broad range of services across multiple specialties, including oncology and cardiology, orthopedic and musculoskeletal procedures, genetic and lab testing, chiropractic care, physical, occupational and speech therapy, home health services, durable medical equipment and more.
Dive Insight:
Providers generally loathe prior authorization, a controversial process requiring them to get an insurer’s OK before providing care. Doctors argue the preapprovals amount to unnecessary red tape that fuels burnout, slows down medical care and leads to worse health outcomes for patients.
Insurers counter that prior authorizations are a valuable tool for ensuring only medically needed and cost-effective care is delivered, a key priority in controlling rampant medical cost growth.
However, prior authorizations have been increasingly villainized. Many Americans report being unable to access healthcare, forced to navigate a funhouse of paperwork and wait days, weeks or even months before they’re able to receive treatment their doctor says they need — and that’s if a service is approved at all.
Mounting discontent over the perception that insurers arbitrarily delay and deny care in order to profit culminated in the killing of UnitedHealthcare CEO Brian Thompson at the end of 2024, a flashpoint that kicked off a moment of reckoning for insurers about the need to improve their relationship with patients and providers.
Since then, carriers have moved to pare back overly burdensome prior authorization processes, nudged by the Trump administration and rule changes from the CMS.
This spring, UnitedHealthcare said it would eliminate 30% of its prior authorizations by the end of 2026, part of its parent company UnitedHealth’s broader review of its business practices as it works to restore its standing with the American public — and with Wall Street, after rising medical costs ate into insurance profits.
Now, UnitedHealthcare has released detailed lists of the CPT codes, five-digit codes that represent medical items and services, included in that cull.
The insurer focused on services with proven evidence of clinical efficacy, and where approval rates are consistently high, according to Eric Hausman, a spokesperson for UnitedHealthcare.
The cuts include more than 800 codes for UnitedHealthcare’s commercial plans, about 940 for its ACA plans and approximately 120 for MA and dual special needs plans.
Codes eliminated for Medicaid providers differ by state, ranging from three codes in Washington, D.C. to more than 600 in Texas.
Meanwhile, UnitedHealthcare’s Oxford plans, which the company offers to employers and individuals mostly in New York, New Jersey and Connecticut, will remove prior authorizations from 1,400 codes.
“We know the time you spend managing prior authorizations, paperwork and reimbursements is time you’d rather spend with your patients,” the memo to providers reads. “Removing these prior authorization requirements is part of our effort to help reduce administrative work, remove barriers that can delay care and give you more time to focus on patient care.”
On Tuesday, UnitedHealthcare also shared a list of providers that newly qualify for its national gold card program, which allows practitioners whose prior authorization requests are consistently approved to perform most procedures without needing to get the health plan’s green light.
UnitedHealthcare is the largest private insurer in the U.S., covering more than 48 million Americans. As such, cuts to its administrative requirements could go a long way for U.S. providers. Yet hospitals and doctors are generally wary about insurer promises to restrict utilization management controls, uncertain that they’ll move the needle on reducing administrative burden or improving timely care access for patients.
For example, major payer and provider groups agreed on the need to improve prior authorizations in 2018. But eight years later, getting treatment approval is still a huge problem for providers, many of which say prior authorization requirements have actually been increasing.
That concern is compounded by evidence that the lion’s share of prior authorization denials are overturned upon appeal, suggesting that care should have been approved in the first place.
Insurers denied at least 1 in 8 standard prior authorization requests in government programs last year, according to a recent analysis by KFF. UnitedHealthcare had the highest denial rate in the privatized Medicare program, at 17%.
