A California-based health insurer is eliminating prior authorization for 50% of radiology CPT codes in an effort to reduce administrative burden and increase efficiency.
LACare Health Plan announced the move on Aug. 7, noting that it would remove 24% of existing codes from its overall PA list. LACare, “the nation's largest public health plan,” said it identified the codes to be removed after a “thorough review” of past utilization authorizations.
“Prior authorization makes sense — it provides important information in a timely manner, ensures patient safety and minimizes fraud,” CEO John Berkes said in the announcement. “But LA Care understands that it should not be used as a cost-control mechanism or as a means to delay or deny appropriate care.”
Medical services that will no longer require pre-authorization include half of lab tests and radiology codes, as well as specialty care such as cardiology, nephrology and dermatology. LACare is also removing durable medical equipment from the list, along with catheter supplies. The company did not provide a complete detailed list of diagnostic imaging services that will be covered under the policy change.
LA Care joins a growing number of insurers moving to scale back prior authorization requirements following outcry from providers, patients and politicians. UnitedHealthcare announced a year ago that it was eliminating prior authorization for more than 60 radiology services. That same month, Cigna said it was removing 25% of its medical services from its PA list, but that didn't include diagnostic imaging services.
One study found that radiology had the third-highest burden from Medicare Advantage prior authorizations, and another analysis concluded that these burdensome utilization management tactics can lead to delayed care, anxiety, and administrative burdens for cancer patients.
LA Care believes removing these codes will provide physicians with flexibility to make “timely, member-centered, medically appropriate decisions.” PAs will always be required for certain services, including hospital level care (excluding childbirth), clinical trials, transplant procedures, unlisted procedures/codes, and work provided by non-contracted providers.
“LACare has heard from providers who say prior authorization has led to adverse events in patient care,” Backes added. “We also understand that prior authorization is impacting physician burnout at a time when there is a growing shortage of physicians to treat the most vulnerable populations that LACare serves.”
This health insurance, under names such as Medi-Cal, LA Care Covered, LA Care Medicare Plus and the PASC-SEIU Homecare Workers Health Care Plan, covers more than 1 in 4 Los Angeles residents.
