Before complex medical treatments, tests, or certain medications qualify for coverage or payment, a “prior authorization” from a patient’s health insurance provider may be required. These authorizations can play an important role in keeping patients safe, improving health outcomes and care experiences, and reducing unnecessary costs.
“We know patients, providers, and lawmakers want the prior authorization process to be faster and easier,” said Dr. Jeff Hankoff, a medical officer at Cigna Healthcare. “We are committed to tracking data and holding ourselves accountable for making authorizations as efficient and seamless as possible for patients and providers. We are also working to drive value-based care to reduce the need for prior authorizations and improve patient outcomes in conjunction with their provider.”
To get a better understanding of prior authorizations and the value they can bring to patients, we sat down with Dr. Hankoff, who walked us through how prior authorization works, why it’s necessary, and how Cigna Healthcare is working to improve the process for its provider partners and the patients we both serve.
When and why do patients need to get prior authorization for a treatment?
Prior authorization is predominantly focused on complex treatments, tests, and certain medications – for example, to help a patient avoid unnecessary exposure to radiation that puts them at increased risk of cancer or to manage opioid prescriptions for at-risk patients. It has proven to be successful. One data point that we are proud of – Since 2014, prior authorizations have led to the potential avoidance of over 500 new cancer cases among Cigna customers by preventing or limiting radiation exposure from medically unnecessary CT scans.
Less than 4% of medical services require a prior authorization for Cigna Healthcare plan members, but when they do, it is really about patient safety and experience, and to avoid unnecessary treatment. That includes looking out for potential issues that might do more harm than good. Since 2020, we have actually removed the prior authorization requirement for about 1,100 services and devices.
Talk to me about the benefits of prior authorization.
Our mission is to help people achieve better health outcomes, and medical management tools like authorizations help us do that.
Prior authorization accomplishes three important goals. First and foremost, it ensures safety for patients. Second, it improves health outcomes by ensuring that patients are treated in accordance with the latest clinical guidelines and evidence-based medicine. Finally, it improves the affordability of health care. By ensuring that the right service is provided in the right place at the right time, we can help ensure better outcomes, often in a more convenient location for the patient, which improves the health care experience.
Unnecessary tests and treatments result in significant costs for health plans and can be expensive for patients, particularly those who have not met their annual deductible. In some cases, if there are clinically equivalent treatment options or sites of care, prior authorization helps ensure the option or site that’s selected is the most cost-effective treatment for the patient’s condition, based on that individual’s coverage.
However, it is important to remember that a prior authorization does not always equate to finding a lower-cost alternative treatment. Based on the circumstances, we may recommend using a more expensive option first, which eliminates unnecessary and potentially harmful steps – saving time while improving outcomes.
Who actually reviews authorizations?
Cigna Healthcare has a dedicated team of nearly 100 medical directors that work alongside our nurses, pharmacists, and other clinical experts to review authorizations and work with patients’ health care providers to expedite approvals or route patients to optimal care. In fact, our medical directors often speak directly with the treating provider to elicit more information on a specific patient, in order to make a more informed decision on the right care.
Cigna Healthcare medical directors are all U.S. based and board-certified to practice medicine. They represent a wide range of specialties – from family physicians, internists, and pediatricians to oncologists and orthopedic surgeons. Many still see patients, for example, using their free time to volunteer in free clinics or cover shifts at local hospitals.
Our team is deeply committed to this work, which is driven by the latest clinical guidelines, and they are focused on reviewing cases efficiently and thoroughly. We each care deeply about achieving the best health outcomes for all those we serve.
Can you share an example of how prior authorizations have helped real patients?
One of our medical directors – who is a spine surgeon – recently did not authorize a lumbar spinal fusion surgery, suggesting extensive physical therapy instead. Once a lumbar spinal fusion is done, it is irreversible – the vertebrae can never move independently again – and unfortunately, many of these surgeries are performed without strong clinical evidence of medical necessity. The patient was unhappy at the time, but he wrote us a letter several months later to say that our approach had worked, saving him unnecessary surgery while improving his health outcome.
What have we done to improve the prior authorization process?
As an industry we’ve made a lot of progress, particularly with the onset of digital technology. AHIP research finds that the prior authorization process is much more streamlined and takes less time when requests are submitted electronically, falling from an average of 18.7 hours to 5.7 hours. That’s a reduction in turnaround time of nearly 70%.
The rapid and accelerating pace of medical innovation makes it more difficult for any individual clinician to track every new recommendation and be sure that certain tests and treatments are reviewed against the latest data and research. Accordingly, we continuously review our authorization requirements to ensure they are appropriate and up to date.
Do we review claims after services have been performed?
We do, to ensure that doctors get paid appropriately and quickly. In fact, we’ve developed an automated process for routine, low-cost screenings and treatments to accelerate payments to providers when the services are submitted with the correct diagnosis codes. If a claim is submitted for one of those tests with an inappropriate code, a medical director reviews it and may send it back to the provider to request additional information. These reviews do not impact the patient, since the service has already been provided and a denial does not result in any additional out-of-pocket costs for patients using in-network providers.