10 Prior Authorization Updates in 2023 

Top-10-prior-authorization-updates-in-2023

In 2023, multiple entities, such as the Health Insurance Company and health Services Company, declared reductions in prior authorizations. Healthcare Media provided further details on this and additional updates related to prior authorizations in the healthcare sector reported this year.

  1. According to a November 13 report from the Medical Group Management Association, 89% of medical groups consider prior authorization to be an extremely burdensome regulatory issue.
  2. On November 6, CMS proposed new health equity changes regarding prior authorization policies within Medicare Advantage organizations. These changes aim to better assess any disproportionate impact on underserved populations that might lead to service delays or denials. The proposed changes are part of a broader rule from CMS and are slated to be effective in the 2025 contract year. Comments on this proposal are due by January 5, 2024.
  3. Starting January 1, 2024, Blue Cross Blue Shield of Massachusetts will eliminate 14,000 prior authorization requirements for home care services for its 2.6 million commercial members. This policy will extend to Medicare Advantage members in 2025.
  4. On September 7, Blue Cross Blue Shield of Michigan announced a reduction of approximately 20% in its prior authorization requirements and an expansion of its gold-card program. The payer’s senior vice president and chief medical officer noted that these changes are part of an ongoing evolution.
  5. A health services company announced on August 24 the removal of prior authorization requirements for over 600 medical procedures, effectively reducing its prior authorizations by 25%.
  6. Health insurance providers executed a 20% reduction in prior authorizations across two phases—first on September 1 and then on November 1. This followed an initial announcement on March 29 indicating the elimination of 20% of existing prior authorization requirements, with plans for a potential national gold care program in 2024.
  7. An audit from the HHS’ Office of Inspector General revealed that, on average, Medicaid managed care organizations denied approximately 1 in 8 prior authorization requests. Out of the 115 MCOs audited, 12 had denial rates exceeding 25%.
  8. Health insurance companies abandoned a planned gastroenterology endoscopy prior authorization policy scheduled for June 1. Instead, they established an advance notification process for non-screening GI procedures.
  9. CMS issued a final rule on April 5 aimed at streamlining Medicare Advantage and Part D prior authorizations and cracking down on misleading marketing practices. Among other provisions, the rule stipulates that coordinated care plan prior authorization policies should only confirm diagnoses or medical criteria and ensure medical necessity for an item or service.
  10. Despite the October 2022 implementation of Texas’ physician gold-card rule, providers haven’t seen the anticipated results, as reported by the American Medical Association on March 1.
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