UnitedHealthcare's 20% Prior Authorization Cut: What Changes for Practices

The prior authorization desk in a typical independent practice is one person, a phone, three payer portals and a spreadsheet. This week that person got some encouraging news and, we think, should change nothing about how they work until the news turns into a code list.

UnitedHealthcare announced on March 29 that it will eliminate prior authorization requirements for procedures that account for roughly 20% of its authorization volume, starting in the third quarter of 2023 and continuing through the year, across most of its commercial, Medicare Advantage and Medicaid plans. The company also said it plans a national "gold card" program in 2024 that would exempt qualifying provider groups from most authorizations. Trade press reported that Cigna and Aetna described their own efforts to trim requirements in the same weeks, without the same headline number.

Key takeaways

• UnitedHealthcare's announcement is a percentage of volume, not a code list. Your requirements are unchanged until the plan publishes the codes and effective dates in its provider bulletins.
• The AMA's survey released this month found 94% of physicians reporting care delays from prior authorization and an average of 45 requests per physician per week.
• CMS's December 2022 proposed rule would set 72-hour and 7-day decision deadlines for Medicare Advantage, Medicaid managed care and Marketplace plans. It is not final.
• Gold card programs are earned with approval rates. Start tracking approval rate by payer and service now so you can check the plan's math in 2024.
• One log for every request, with turnaround and outcome, is the tool that makes any of this measurable.

Why now

Two pressures came together. In December 2022, CMS proposed a rule that would require Medicare Advantage, Medicaid managed care and Marketplace plans to answer urgent prior authorization requests within 72 hours and standard requests within 7 calendar days, to give a specific reason for denials, to publish approval and denial metrics, and to support authorization through a standard electronic interface. That rule is still proposed, but the direction is clear.

The second pressure is the AMA's prior authorization physician survey, released this month, covering the 2022 experience of 1,001 practicing physicians. The AMA has run a version of this survey for several years and the numbers have not improved.

The survey is the physicians' side of the story and the plans dispute parts of it every year. But the numbers on volume and time match what we see in practices: two business days a week of someone's time, per physician, is a real cost, and it is the reason a 20% cut in requirements gets attention even before anyone knows which 20%.

What UnitedHealthcare actually said, and what it did not

The announcement described a percentage of volume, not a list of codes. Until the plan publishes the specific procedures and effective dates in its provider bulletins, your prior authorization requirements are unchanged. A 20% reduction in the plan's authorization count could mean removing a few very high-volume, rarely denied codes (think routine imaging or some genetic tests) while leaving the surgeries and infusions your practice fights about untouched. We hope that is not the case. Plan for it anyway.

Note also what a gold card program requires: a documented approval rate above a threshold over a lookback period. Practices that want to qualify in 2024 need to be tracking their own approval rates by payer now, because the plan will calculate it from its own data and you will want to be able to check the math. Texas's gold card law, in force since 2021, uses a 90% approval rate over a six-month review period as its threshold; whatever UnitedHealthcare chooses, expect something in that range.

The same week: CMS finalized 2024 Medicare Advantage payment

On March 31, 2023, CMS released the calendar year 2024 Medicare Advantage and Part D rate announcement. Payments to MA plans are expected to rise 3.32% on average from 2023 to 2024, and CMS finalized an updated risk adjustment model that moves to ICD-10 condition categories and removes or constrains some categories that CMS said were subject to coding variation. The model will be phased in over three years. This follows the January 30, 2023 final rule on risk adjustment data validation audits, under which CMS will extrapolate audit findings starting with payment year 2018 without applying a fee-for-service adjuster.

Why this matters to a prior authorization desk: MA plans are being paid a smaller increase than they asked for and face larger audit exposure, and utilization management is one of the levers they control. We would not expect Medicare Advantage authorization requirements to loosen as quickly as commercial ones. Expect more record requests for risk adjustment as well, since plans will want every documented diagnosis to survive the new model.

How to run the desk regardless of what payers promise

1. One log, every request. Date requested, payer, member, CPT and diagnosis, method (portal, fax, phone), reference number, status, decision date, authorization number, approved units and date range. If this lives in three portals and a memory, you cannot measure it.
2. Turnaround by payer. Days from request to decision, median and 90th percentile, per payer per month. This is the number that the December proposed rule would regulate and the number that supports a complaint to the plan or the state insurance department when it is bad.
3. Approval rate by payer and by service. This is the gold card number. It also shows you where clinical documentation is not matching the plan's criteria, which is a fixable problem.
4. A requirement check before scheduling, not after. The scheduler checks the payer's current requirement list for the CPT code when the procedure is booked and creates the authorization task then. Requirement lists change quarterly; assign someone to download them.
5. Denials sorted by cause. CO-197 (precertification or authorization absent) means nobody requested it. CO-15 (authorization number missing, invalid or does not apply) usually means the number was obtained but not on the claim, or the units or dates were exceeded. The two have different fixes and different appeal odds. A CO-197 where the payer allows retro-authorization within a window is worth an immediate call; one where it does not is a training conversation.
6. Peer-to-peer within the window. Most plans allow a physician-to-physician review before a formal appeal, and the window is short. Put the deadline in the log and give the physician a one-page summary, not the chart.

What the log shows after one quarter

A fictional orthopedic practice ran the log for January through March. It requested 412 authorizations. Median turnaround was 3 business days for one national plan and 9 for another; the 90th percentile for the slow plan was 21 days, which explained a recurring pattern of surgeries rescheduled at the last minute. The overall approval rate was 91%, but for one MRI code with one plan it was 62%, and every denial cited the same missing element: six weeks of documented conservative treatment. The fix was a template line in the clinic note, and the desk stopped spending hours a week on appeals for that code. The practice also found 14 CO-197 denials worth about $19,000 where the authorization had never been requested because the procedure was added to the schedule after the initial booking. That produced a rule: any schedule change to a procedure re-runs the requirement check.

None of that came from a payer announcement. All of it came from a spreadsheet with the right columns.

Questions we hear

Should we stop requesting authorization for UnitedHealthcare procedures in July?

No. Only stop when the specific CPT code appears on the plan's published removal list with an effective date, and keep a copy of that bulletin with the date you downloaded it. A claim denied CO-197 after the code was removed is an easy appeal with the bulletin attached. A claim denied because you assumed is not.

Does the December CMS proposal help us with commercial plans?

Not directly. The proposed rule covers Medicare Advantage, Medicaid and CHIP managed care and Marketplace plans, not employer-sponsored commercial coverage. Some states have their own prior authorization laws with turnaround limits and gold card provisions (Texas has had one since 2021), and those do reach commercial plans regulated by the state. Self-funded employer plans are outside both.

Is any of this going to reduce our staffing on authorizations?

Honestly, not in 2023. The volume of requests may fall somewhat in the fourth quarter if the UnitedHealthcare list is meaningful. The work of tracking, appealing and documenting stays. If the desk is one overwhelmed person, the log above is the first thing to build, and Revelrex denial management handles the CO-197 and CO-15 side of the problem for practices that would rather outsource it.

What to do this month

1. Build the authorization log with the columns listed above, or add the missing columns to the one you have, and start every request in it from Monday.
2. Download the current prior authorization requirement lists for your top five payers, date them, and put the next quarterly download on the calendar.
3. Pull the last quarter's CO-197 and CO-15 denials and sort them into never requested, number missing from the claim, and units or dates exceeded.
4. Calculate the approval rate by payer for the last quarter from whatever records exist, even if incomplete, so you have a starting point for the gold card conversation.
5. Subscribe the desk to UnitedHealthcare's provider bulletin and set a reminder to look for the published code list in the third quarter.