Four Strategies to Improve Prior Authorization Impact On Your Business
UnitedHealth Group Provides Fact Sheet on Medical Claims (10% Denial Rate Reported)
Dec. 13, 2024
“UnitedHealth Group today provided the following information regarding UnitedHealthcare’s medical claims approval rate:
- UnitedHealthcare approves and pays about 90% of medical claims upon submission.
- Of those that require further review, around one-half of one percent are due to medical or clinical reasons.
- About half of those not paid initially are due to administrative errors, such as missing documentation, which can be corrected.
- The majority remaining are due to factors such as an individual not having insurance coverage with UnitedHealthcare or duplicate claims submissions.
- Any other numbers being discussed in some quarters purporting to be the UnitedHealthcare approval rate are wrong.”
UHC Fact Sheet on Medical Claims
UnitedHealthcare Denial Rates and Slow Payments Hamper Talks, OHSU Says (56% Denial Rate Reported)
Feb. 3, 2025
“For its part, OHSU says UnitedHealthcare has a 56.4% denial rate, compared with the industry standard of 5% to 10%, an OHSU spokeswoman said in an email. It takes UnitedHealthcare an average of 307.3 days to resolve claims, the longest of all of the insurance companies that OHSU does business with.
UnitedHealthcare accounts for 48% of all peer-to-peer denials at OHSU. A peer-to-peer denial is a conversation between an OHSU provider and an insurer’s medical director that occurs when a payer denies a claim.”
All PA Denials Negatively Impact Your Business and the Lives of Surgeons and Patients
The true PA denial rates for an innovative procedure with any insurer are unknown at this time.
As a Healthtech CEO and practicing Rhinologist, I have witnessed firsthand how the current prior authorization (PA) process—marked by frequent denials and burdensome peer-to-peer interactions—undermines the adoption of innovative medical devices, delays patient care, and drives burnout in healthcare providers. Addressing these inefficiencies is not only critical to our industry’s growth but also to improving patient outcomes.
Below, I outline several strategic approaches, ranked by their potential impact, along with specific steps that medical device executives can consider to help drive meaningful change:
Process Innovation:
Modernizing the PA submission process is paramount. Recent advancements have shown that integrating artificial intelligence into workflow systems can dramatically reduce, or even eliminate, the need for traditional peer-to-peer reviews. For example, practices can experience near-immediate benefits by leveraging AI to interface directly with insurer algorithms. This shift not only streamlines administrative tasks but also lowers operational costs.
Action Step: Consider partnering with technology innovators to develop AI-powered PA solutions that enhance device utilization and streamline administrative processes.
Public Perception and Market Dynamics:
Increased public scrutiny of insurers’ profit-driven motives—exemplified by the challenges seen with companies like UHC—creates a unique opportunity for market-driven reform. As patients and providers become more vocal about the negative impacts of PA Denial processes, there is potential for a shift in consumer behavior and market dynamics.
Action Step: Support and fund robust, real-world data collection that quantifies the adverse effects of current PA practices on innovative device usage. This evidence can be instrumental in shaping public opinion and influencing insurer practices.
Legislative Reform:
Legislative initiatives, such as H.R. 2433 (the Reducing Medically Unnecessary Delays in Care Act), are designed to minimize administrative delays and expedite patient care. While initial legislative reforms may primarily target Medicare and Medicare Advantage plans, there is a broader opportunity for the industry to push for changes that also impact commercial insurers.
Action Step: Engage with policymakers by providing comprehensive data and case studies that highlight how excessive PA procedures hinder access to innovative devices, thereby advocating for broader legislative reforms.
Regulatory Oversight:
Strengthening regulatory oversight by reporting denial practices can contribute to longer-term improvements in the PA process. Although current legal challenges against insurers may take years to resolve, transparent and consistent reporting can set the stage for more accountable practices in the future.
Action Step: Collaborate with professional societies and regulatory bodies to develop standardized reporting frameworks that objectively document PA denials and their impact on device usage and patient care.
By embracing these strategies, medical device leaders can play a pivotal role in transforming the PA landscape—ultimately enhancing product accessibility, reducing administrative burdens for physicians, and, most importantly, improving patient outcomes.
Fire up!