
UNH Prior Authorization Changes To Date Unlikely To Significantly Impact Genetic Labs or Imaging Centers; Despite Lobbying Against Burdensome Barriers to Care, to Date There Has Been Minimal Impact
In March UnitedHealthcare, the largest commercial payer with over 30 million covered lives, announced prior authorization changes to a number of procedures comprising 20 percent of its current prior authorization volume. These changes took effect on September 1st and while at first glance this appears to be a major win for genetics and radiology providers which comprised the largest number of affected CPT codes, a closer examination appears to show that it will have minimal impact. Noticeably absent from the list were many of the most highly utilized or highly reimbursed codes for certain procedures such as genetic testing or high-volume MRI codes. Additionally, United Healthcare has actively put in place additional prior authorizations for high volume procedures such as diagnostic and screening colonoscopy which physician’s believe will dramatically negatively impact patient care. It appears the program may be a bait and switch effort comprising mostly low revenue codes, and while other payers are likely to follow UnitedHealth’s lead, it is apparent real reform is unlikely to occur under the current program. In fact, despite increased lobbying against payers by physicians to reduce onerous prior authorization requirements, a survey by the Medical Group Management Association found that 80% of physicians reported increasing prior authorization requirements from 2021 to 2022.
UnitedHealthcare’s policy changes are likely in response to increased lobbying by medical groups who have been much more vocal in complaining about the excessive burdens of the prior authorization (PA) process. The American Medical Association’s number tenant in its AMA Recovery Plan for American Physicians is prior authorization reform. A 2022 physician survey by the American Medical Association is a significant condemnation of the current prior authorization process. 80% of physicians reported prior authorization requirements led to patients sometimes or greater abandoning care. 31% of physicians stated that PA guidelines are rarely or never evidence based, and 89% of doctors stated that prior authorizations have a somewhat or significant negative impact on patient outcomes. It is also estimated that two fifths of physician staff work exclusively on PAs which average 45 PAs per physician per week. On average, prior authorizations cost physicians $11 each when manually processed, however burdensome prior authorizations for advanced procedures can cost $35 to $100 per prior authorization.
The American College of Gynecology has also been vocal about inappropriate prior authorization requirements for genetic testing. The physician group has expressly stated that prior authorizations are inappropriate for non-invasive prenatal screening (NIPS). Despite these changes, UnitedHealthcare did not eliminate prior authorization requirements for CPT code 81420 in its recent changes, the most commonly billed CPT code for NIPS. In fact United Healthcare, with approximately 30 million lives under coverage remains the only top five payer with prior authorization requirements for NIPS still in place.
ACOG has also come out against prior authorization requirements that require genetic counseling by a board certified genetic counselor. Despite strongly worded position statements, certain payers such as CIGNA continue to require counseling by a board certified genetic counselor or geneticist prior to approving payment for tests such as hereditary cancer testing. These programs have detrimentally impacted testing volume when the excessive burden placed upon the patient and ordering gynecologist and in many cases led to non-payment of claims given the lack of adherence to the onerous policy.
Looking at the impacted codes for genetic testing there are clear examples of non-highly utilized codes being represented and highly utilized codes being absent in the prior authorization changes. For instance, in hereditary breast cancer testing, highly utilized CPT codes including 81162, 81163, 81432, 81433, and company specific codes are absent while low priced, relatively unutilized codes such as 81165, 81166, 81167, 81212, 81215, 81216, and 81217 are present. For MRI procedures, none of the most commonly utilized CPT codes for brain and neck, spine, breast studies, joints, or extremities were included in the prior authorization changes. Prior authorizations can also be expensive for payers to process and eliminating prior authorizations for lower reimbursed codes or low volume procedures may ultimately benefit or come at no cost to a payer’s bottom line.
Finally, less publicized by UnitedHealthcare were new preauthorization requirements in areas such as diagnostic colonoscopies which were scheduled to take effect June 1st. Based upon pressure from patient advocacy organizations such as Fight CRC and the Colorectal Cancer Alliance along with physician groups, UnitedHealthcare removed this policy. However, UnitedHealthcare replaced the prior authorization changes with new data collection requirements that increase the burden on physicians. In response to the new data requirements, Barbara Jung M.D., the head of the American Gastroenterological Association stated: “From UnitedHealthcare’s slap-dash approach to rolling out a policy that will ultimately control patient access to critical, often life-saving, medical procedures flies in the face of common sense and responsible medical practice. It also indicates that UHC does not currently have data that shows any significant overutilization of critical endoscopy and colonoscopy procedures that would ostensibly justify this program or prior authorization.”
These types of excessive data collection programs can be burdensome on providers and as payers often deny claims when there is an error in any entered data. One area where payers such as Aetna are increasingly adding burdens to providers is by requiring medical records for all claims, including chart notes from physicians. These processes can be even more burdensome for providers than current prior authorization systems. Among genetic testing laboratories, these types of programs can lead to non-payment rates representing almost half of claims, despite the majority of these patients meeting payer medical policy.
In 2024, UnitedHealthcare will launch a gold card program where patients with gold cards (who UNH says will be the majority of its members) can go to “qualifying providers,” and eliminate prior authorizations for most procedures. UNH has said it will provide more detail on this program later this year. What is unclear is the qualifying provider language and what criteria will be used to determine a qualifying provider. This tool could be a means to push patients to lower cost sites of care. UNH and other payers often offer preferred networks with access benefits such as UNH’s preferred laboratory network but entry into these networks typically requires pricing concessions from the provider and typically comprise lower cost providers such as the large national reference laboratories. We will be closely monitoring this program for updates.
Some reforms have been more meaningful – The Centers for Medicare and Medicaid Services (CMS) implemented changes for Medicare and Medicare Advantage plans where plans must 1) Include specific reasons for denying a test, 2) Publicly reporting prior authorization metrics, and 3) sending decisions within 72 hours for expedited claims and 7 days for routine claims 4) and limits plans abilities to add additional burdensome requirements to prior authorizations. Furthermore proposed rules would require plans to upgrade to electronic systems by 2026. A bipartisan group of legislators including 300 members of Congress encouraged CMS to finalize these changes in a public letter in June. Based on our discussions with service providers, these changes are helpful in resolving prior authorizations and have been lauded by physician groups. Andy Gilberg from the MGMA in speaking to the Medicare changes said, “An alarming number of medical groups report completing prior authorization requests via paper forms, over the phone, or through varying proprietary online payer portals. The onerous methods of completing these requests, coupled with the increasing volume is unsustainable. An electronic prior authorization program, if implemented appropriately, has the potential to alleviate administrative burden and allow practices to reinvest resources in patient care. This is a positive step forward for both medical groups and the patients they treat.” However, based on feedback from providers, most commercial plans will likely separate medical policy for their Medicare Advantage and commercial lives and maintain current policies on commercial books of business.
Currently it is unclear if more significant prior authorization reform is on the horizon, however providers are clearly ramping up the battle with payers to alleviate overly burdensome systems which could lead to positive changes for the healthcare industry over time. However, the current changes proposed by UnitedHealthcare and most other commercial payers to date seem unlikely to dramatically impact providers in genetic testing or radiology at this time.