Tag: Prior Authorization

YARMOUTH, Maine – Prior authorizations have their uses, but they also create a heavy burden with no guarantee of payment, say 58% of respondents to a recent HME Newspoll.  “Prior authorization is fine if the insurance plan honors their end of the agreement,” wrote one respondent. “To do all the work to obtain the PA only to receive a denial is very frustrating. Even more frustrating is to have the plan tell you that prior authorization is not a guarantee of payment.”  Prior...

YARMOUTH, Maine – It was big news when UnitedHealthcare announced it would reduce the number of product codes requiring prior authorizations. Cigna soon followed suit and then Blue Cross Blue Shield of Michigan and others. While it was big news, it wasn’t surprising.  The American Medical Association (AMA) has been on a fierce campaign to reduce prior authorizations. On its website, the AMA characterizes it this way: “Prior authorization is a health plan cost-control process...

BLOOMFIELD, Conn. – Cigna has removed prior authorization requirements for nearly 25% of medical services. With the removal of these 600-plus codes, the insurer has now removed prior authorization requirements on more than 1,100 medical services since 2020. "Our goal is to help keep patients safe, improve health outcomes, and make care more affordable, and this important step will enable us to do that while removing administrative burdens on the health care system," said David Brailer, MD,...

WASHINGTON – UnitedHealthcare’s plan to reduce prior authorizations was met with skepticism by industry stakeholders who say it’s more likely a public relations move in response to increased government scrutiny.  In August, UnitedHealthcare said it would begin a two-phased approach to eliminating prior authorizations for many product codes starting Sept. 1, 2023. That’s after the Senate Homeland Security and Government Affairs Committee in May held a hearing on...

CLEARWATER, Fla. - Lincare has filed a lawsuit in Connecticut district court against former CEO Crispin Teufel, who plans to join competitor AdaptHealth on Sept. 1, for breach of contract, breach of duty of loyalty and misappropriation of trade secrets.  Lincare seeks a temporary restraining order, preliminary and permanent injunctive relief, damages and attorney fees.  “Since defendant’s resignation, plaintiffs have uncovered evidence demonstrating that defendant used...

EDINA, Minn. – UnitedHealthcare says it will begin a two-phased approach to eliminating the prior authorization requirement for many procedure codes starting Sept. 1, 2023, to help reduce the administrative burden on health care professionals and their staff.  This move will reduce the payer’s overall prior authorization volume by nearly 20%.  “This is part of our comprehensive effort to simplify the health care experience for our members and network health care...

WATERLOO, Iowa – VGM & Associates encourages providers to supply the Office for Program Operations and Local Enforcement at CMS with examples of Medicare Advantage organizations denying prior authorizations and claims for several important categories of DME. “We understand the urgency surrounding these issues and have been talking with them about the best process to resolve them,” VGM stated in a recent bulletin. “In addition to those efforts, several of our members have asked...

CHICAGO – The American Medical Association has adopted a new policy calling for greater regulatory oversight of health insurers using artificial intelligence (AI) to review patient claims and prior authorization requests. The newly adopted policy calls for health insurers using AI to implement a thorough and fair process that is based on clinical criteria and reviews by physicians and other health care professionals with expertise for services under review, and that has no incentive to deny...

ALEXANDRIA, Va. – The home infusion community has longstanding partnerships with commercial payers, but there’s always room for improvement when it comes to providing high quality care at the lowest possible cost, says Connie Sullivan, president and CEO of the National Home Infusion Association.  The NHIA recently developed recommendations that it says will get a dialogue going between payers and providers.  “We started talking with our members about, ‘Where...

WASHINGTON – The Better Medicare Alliance, a research and advocacy organization, believes a CMS proposed rule on prior authorizations for Medicare Advantage plans will help to coordinate safe, effective care and streamline the process. “While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization’s essential function in coordinating safe, effective, high-value care, while also building on the Medicare Advantage...