Get the facts: Why is prior authorization needed?

• Health plans use prior authorization to verify that healthcare services are covered by your health plan and meet the standards for quality and safety before you undergo a procedure or surgery. It’s also an important tool to protect you from unexpected costs.
• Prior authorization is not as common as you might think. When UnitedHealthcare members seek care, it’s not needed 98% of the time.
• UnitedHealthcare is committed to not only making the prior authorization process faster, simpler and more transparent but also to reducing its requirements so that prior authorization is used only when it truly improves care.

“Without health, nothing else matters.” Many of us are familiar with this saying, and it resonates for a reason — because it’s true. That’s why our relationships with the doctors who care for us are so important. We’ve entrusted them with the all-important work of keeping us healthy or restoring us to health when we’re sick or injured so that we can get back to doing the things we love. That’s also why anything that feels like it disrupts that trusted bond with our doctors, such as a request for prior authorization, is understandably unpopular. When you and your doctor have decided on a care plan, being told an extra step is needed can feel frustrating and stressful, especially when you’re focused on getting better.

Most of us never go through this experience because prior authorization — sometimes called prior approval — is not as common as you might think. When UnitedHealthcare members seek care, it’s not needed 98% of the time.¹

Read on to learn more about the purpose of prior authorization, the role it plays in keeping care safe and affordable, and the work that’s underway to further reduce prior authorization requirements.

Checkpoints exist throughout the American healthcare system. They’re designed to ensure people receive appropriate care and avoid preventable errors in treatment or diagnoses. While doctors and hospitals manage most of these checkpoints, health insurers also play a role. The most familiar example is prior authorization.

• Health plans use prior authorization to verify that healthcare services are covered by your health plan and meet widely accepted standards for quality and safety before you undergo a treatment, procedure or surgery.
• This makes it an important tool to protect you from unexpected out-of-pocket costs.
• Prior authorization is one of the few tools available to help prevent overtreatment and low-value care, which are far too common in our health care system.

For all the recent noise around prior authorization, the reality is it’s rarely used and is not required for most types of care.

• When UnitedHealthcare members seek care, prior authorization is not needed 98% of the time.¹
• In rare instances when it is required, more than 90% of requests are approved.¹

UnitedHealthcare most frequently uses prior authorization in the following scenarios:

• A condition can be treated in multiple ways that vary in quality, outcomes and cost: For example, many procedures that used to require inpatient stays in hospitals can now take place in outpatient facilities where quality outcomes are as good or better than at inpatient facilities, stays are shorter, and risks of hospital-acquired infections are reduced.
• The care guidelines that are generally accepted by physicians and medical societies have evolved: An example could include when new treatment guidelines for chronic conditions are released or when the FDA approves a new drug or the use of existing medications to address new conditions.
• A procedure or medication comes with a high price tag and could lead to high out-of-pocket costs for the member: The purpose of prior authorization in this scenario is to encourage the use of the safest and most appropriate treatment or service and ensure that everyone is clear on what’s covered before treatment begins. Prior authorization can be especially useful in these cases as it can help ensure you understand all the options available to treat your condition, including those that are equally as effective but significantly less expensive for you.  

Federal and state regulations require health insurers to review and process prior authorization requests in a timely manner so that both doctors and patients have as much advance notice as possible if a request is not approved. It’s rare for the notification to reach the member just before they’re scheduled to undergo surgery or a medical procedure.

The primary reasons this would happen are:

• The provider didn’t submit the prior authorization request far enough in advance of the date of the scheduled surgery or procedure.
• The health insurer requested additional medical records to support the processing of the prior authorization request, and the time it took the provider to submit the records further delayed the processing of the request.
   

Regulations require insurers to communicate decisions about prior authorization requests in the form of a letter sent in the mail unless the member has opted in to receive communications from the plan via email. The time it takes for the U.S. Postal Service to deliver the notification letter to a member’s home can further delay the notification process.

We understand how upsetting it can be for members to find out that their prior authorization request was not approved just before they’re set to undergo a surgery. The anticipation of a major medical procedure is stressful and even scary, and most of us in these situations just want to get it over with.

We don’t want to cause additional stress for our members during vulnerable moments. That’s why we’re working to improve and streamline the prior authorization process so that these types of situations, which are already rare, occur even less frequently, with the ultimate goal of preventing them altogether. 

As part of those efforts, we are increasing the use of electronic submission of prior authorization requests, which enables a much faster response to the provider. Because of this transition to electronic processing of prior authorization requests, we now approve nearly half of all requests in real-time, and almost all decisions are made within 24 hours.¹

We also encourage our members to opt in to receive communications and notifications from their health plan via email or the UHC mobile app. Members can find a prior authorization tracking tool on our member portal as well as the UHC app that can be useful to track the status of their prior authorization request in real time.

Most members don’t receive care that requires prior authorization, and for those that do, we approve nine out of 10 prior authorization requests.¹ But regardless, we know prior authorizations are frustrating for members and providers and can feel like an unnecessary complication in their care journey. That’s why we’re committed to not only making the process faster, simpler and more transparent but also to reducing our prior authorization requirements so that it’s used only when it truly protects members and improves care. 

• We have made substantial progress in reducing the number of services that require prior authorization:

o   In 2023, we eliminated the requirements for nearly 20% of our prior authorization volume, particularly in cases where there was minimal variation in how care is delivered.

o   We continued that effort last year by removing requirements representing nearly 10% of our total prior authorization volume.

o   By the end of 2026, we will eliminate an additional 30% of prior authorization requirements, including for select outpatient surgeries, some diagnostic tests like echocardiograms, and certain outpatient therapies and chiropractic care. 

o   Specifically for our Medicare Advantage members, we’ve reduced the number of services subject to prior authorization by 40% since 2016. Today, UnitedHealthcare has fewer prior authorization requirements for our Medicare Advantage members than any other insurer.

• We introduced a first-of-its-kind national Gold Card Program in 2024, which recognizes provider groups who consistently follow evidence-based care guidelines by exempting them from prior authorization requirements for many procedures. Now in the program’s second year, we’ve seen a more than 40% increase in the number of provider groups that have qualified. In a survey of the provider groups most active in the program, 94% reported being satisfied with it, and that same percentage agreed that the program has reduced administrative tasks.
• By the fall of 2026, we will exempt rural providers from most of the medical prior authorization requirements that exist today. This exemption will apply to approximately 1,500 rural hospitals — including all Critical Access Hospitals — and their associated rural practitioners caring for members enrolled in all types of UnitedHealthcare health plans.
• We will remove two-thirds of authorization requirements for members under age 18 by the end of 2026, including for many diagnostic services, routine surgical procedures, and specialty care services across pediatric subspecialties such as cardiology, neurology, pulmonology and orthopedics.

As part of our efforts to simplify and streamline the consumer and provider experience, we are advancing digital tools that enable electronic submission of prior authorization requests. This results in a much faster decision and response to the provider. Because of this transition to electronic processing of prior authorization requests, we now approve nearly half of all requests in real-time, and 92% of decisions are made within 24 hours.²

Together, these efforts will make it easier for members to get the care they need when they need it and for doctors to spend more time with their patients. As these initiatives progress, members and providers alike can expect an even smoother, more efficient and more transparent experience while we continue supporting safe, appropriate and affordable care.

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