Variation and Standardization in Prior Authorization Requirements
Listed in
This article is not in any list yet, why not save it to one of your lists.Abstract
Importance
Prior authorization rules are neither regulated nor standardized and contribute to wasted spending, delays in care, and physician burnout.
Objective
To examine and compare the prior authorization rules of large private US insurers.
Design
This study converted prior authorization rules into a single framework; quantified variations, inconsistencies, and contradictions within and across insurers; and developed a single algorithm to reproduce and compare the prior authorization rules of all insurers.
Setting
Prior authorization rules from the providers manuals of Humana, United Healthcare, Anthem California, and Aetna.
Participants
The prior authorization rules for in-network providers and internally managed contracts were included while the rules for out-of-network providers, for determining provider network status, and for services managed by external vendors were excluded.
Results
The provider manuals cover 19,637 services and medications. Of these, Humana requires prior authorization for 3,048, United Healthcare for 2,682, Anthem California for 2,188, and Aetna for 842. To determine if PA is required, Anthem California provides a medical criteria document for each service and medication. The other insurers use six criteria for varying sets and categories of services and medications. There are 18 potential requirements to obtain prior authorization from Anthem California and a total of five across the other insurers. The manuals contain duplicated, ambiguous, and contradictory guidelines.
Conclusions
In an analysis of the provider manuals of four large US insurers, prior authorization rules differed significantly across services within each provider manual and across provider manuals. The rules were reproduced with a simple framework of 6 criteria to determine if prior authorization is required and 23 requirements to obtain prior authorization, providing an empirical example of a single standardized contract reproducing the rules of several contracts from different large health insurers. The methods presented to standardize and simplify contracts may help inform efforts to rationalize and improve the prior authorization process as well as broader efforts to reduce administrative costs and waste through standardization.
Key Points
Question
Do prior authorization rules, purportedly derived from evidence-based coverage policies, differ across large private US insurers?
Finding
Prior authorization rules differed significantly across services and across insurers with contradictions and inconsistencies. The rules were reproduced with a framework of 6 criteria to determine if prior authorization is required and 23 requirements to obtain prior authorization.
Meaning
The methods presented to reproduce the prior authorization rules of four large insurers in a single framework may help inform efforts to standardize the prior authorization process. The present approach may inform broader efforts to reduce administrative costs and waste through contract standardization.
