Aetna updates on prior authorization reform

Dive Brief:

-- Aetna provided an update on its efforts to streamline the healthcare experience on Thursday, one year to the day after the fatal shooting of UnitedHealth’s top insurance executive sparked a wave of promises from insurers to reform some of the biggest pain points for doctors and patients.
-- This year, the CVS-owned insurer has added new prior authorization bundles for specific conditions, which allow providers to submit one request encompassing multiple prescriptions and medical procedures for a single review.
-- Aetna has also expanded a program that brings Aetna nurses into hospitals to help members transition between sites of care.
Dive Insight:

Many major insurers pledged to fix some much-maligned business practices after the killing of UnitedHealthcare CEO Brian Thompson unleashed Americans’ pent-up anger over delays and denials of care. The backlash was especially directed at a process called prior authorization, which requires providers to get an insurer’s permission before performing a medical service.

Doctors and patients contend that prior authorization contributes to burnout, slows down the provision of medical care and can lead to worse health outcomes. Insurers generally defend the process as an important check to ensure patients are getting medically necessary, safe and effective care.

Still, payers have pared back their prior authorizations in the wake of Thompson’s killing. In June, the largest health insurance companies in the U.S. committed to reduce the number of claims subject to prior authorization by next year, and make other changes that should result in faster access to treatments for patients and fewer administrative hoops for providers.

That same month, Aetna said it would bundle certain prior authorization approvals and expand its Aetna Clinical Collaboration program for transitions between sites of care. And on Thursday, the payer, which covers almost 27 million members, provided an update on its progress.

The payer now provides preauthorization bundles for musculoskeletal conditions that include X-rays, knee surgeries, certain medications and other care, along with its bundles for multiple requests for MRIs or CT scans for patients with lung, breast or prostate cancer, Aetna said.

Aetna plans to continue looking for additional conditions where it makes sense to bundle approvals, particularly in the cancer space, a spokesperson said over email.

As for ACC, the program, in which Aetna nurses work onsite at healthcare facilities to help coordinate member transitions back to the home or other care sites, is now being rolled out in 17 hospitals.

“Aetna Clinical Collaboration has received tremendous interest from the provider community,” the spokesperson said. “We anticipate even further expansion next year.”

Aetna also said its weaving generative artificial intelligence into its Aetna Health app and making other technological upgrades to operations like claims processing and client onboarding.

Despite the flurry of pledges from insurers, patients and physicians remain skeptical that the promises will translate into comprehensive reform of the complex healthcare system. June’s prior authorization pledges, for example, are voluntary and include little outside oversight from the federal government.

Physicians argue that they’ve seen this film before: For example, major payer and provider groups agreed on the need to improve prior authorizations in 2018. But seven years later, getting treatment approval is still a huge problem for providers, many of which say prior authorization requirements have actually been increasing in recent years.

Sydney Halleman contributed reporting.