Humana pledges to accelerate reductions in time, number of prior authorizations

Health insurance giant Humana Inc. will accelerate its efforts to cut prior authorizations and the time it takes to do them.

The Louisville, Kentucky-based insurer announced its plan “will reduce the number of prior authorization requirements and make the process faster and more seamless, while preserving the system of checks and balances that protects patient safety by ensuring the most high-cost, high-risk treatments are reviewed and approved before care is delivered.”

“Today’s health care system is too complex, frustrating, and difficult to navigate, and we must do better,” Humana President and CEO Jim Rechtin said in the company’s news release. “We are committed to reducing prior authorization requirements and making this process faster and more seamless to better support patients, caregivers, physicians, and health care organizations.”

Insurers say change is coming

The company said its announcement builds upon the recent series of commitments to streamline, simplify, and reduce prior authorizations made by health plans, including Humana, that were announced by AHIP, the trade group for America’s health insurance payers, and the Blue Cross Blue Shield Association. Last month, AHIP and a coalition of health plans announced new measures to improve the PA process by streamlining it, reducing prior authorizations, and increasing communication and transparency on determinations. Then, physician group leaders expressed cautious optimism, largely due to previous unfulfilled pledges to reform prior authorizations.

MA and PA in Congress

Humana’s announcement also was published approximately eight hours before the July 22 hearing in the U.S. House of Representatives, “Joint Health and Oversight Subcommittee Hearing on Medicare Advantage: Past Lessons, Present Insights, Future Opportunities.” In their opening statements, the lawmakers did not mention Humana specifically and it did not appear Humana had a representative at the hearing.

However, the lawmakers had comments about their constituents complaining about prior authorizations. Humana also has been a national leader managing Medicare Advantage (MA) plans. As of December 2023, the American Medical Association ranked Humana as the second largest health insurer by market share in metropolitan statistical area and nationally, second only to UnitedHealth Group.

Setting goals

Humana set a date of Jan. 1, 2026, to complete its new goals:

• Eliminating approximately 1/3 of prior authorizations for outpatient services. That includes PA for colonoscopies, transthoracic echocardiograms and select CT scans and MRIs.
• One-business-day turnaround for decisions on at least 95% of all complete PA requests. The company said it provides a decision within one business day on more than 85% of outpatient procedures.
• A national gold card program for physicians to waive PA requirements for certain items and services for physicians and other clinicians “who have a proven record of submitting coverage requests that meet medical criteria and delivering high-quality health care with consistent outcomes for Humana members.”
• Publicly reported prior authorization metrics – including prior authorization requests approved, denied, and approved after appeal, and average time between submission and decision. Humana announced the company “is working to expedite implementation of the new federal transparency requirements.”

Technology for transactions

Computer program interoperability among data systems helps doctors, hospitals and health plans share information needed for patient care, according to Humana’s announcement. The company aims to enhance its electronic health record integration so physicians and other clinicians can stay in existing workflows to submit PA requests. That will reduce administrative burdens and transaction times, according to plans.

Humana also will support greater use of electronic submission, instead of facsimile machines or telephone, to modernize and streamline electronic prior authorization requests. Expedited e-requests will “deliver a better, more seamless end-to-end experience for patients, providers, and payers,” the company’s announcement said.