Health insurer eliminates prior authorization for 50% of radiology codes

A California-based health insurer is eliminating prior authorization for 50% of radiology CPT codes as it aims to reduce administrative burden and increase efficiency.

L.A. Care Health Plan announced the move on Aug. 7, noting that it is removing 24% of existing codes from the overall PA list. The “largest publicly operated health plan in the country,” L.A. Care said it pinpointed codes to exclude after an “extensive review” of historical utilization approvals.

“There is a place for prior authorization. It provides crucial timely information, ensures patient safety and minimizes fraud,” CEO John Baackes said in an announcement. “But L.A. Care understands that it shouldn’t be used as a cost-control mechanism, or as a way to delay or deny appropriate care.”

Medical services no longer requiring prior authorization will include half of lab tests and radiology codes, along with specialty care office visits in cardiology, nephrology and dermatology, among others. L.A. Care also is eliminating durable medical equipment from the list, along with catheter supplies. The company did not offer a full detailed list of which imaging services are covered by the policy change.

L.A. Care joins a growing number of payers making moves to reduce prior authorization requirements amid outcry from providers, patients and politicians. UnitedHealthcare announced a year ago that it was eliminating prior authorization for over 60 radiology services. The same month, Cigna announced it was removing 25% of medical services from its PA list, though none of them were in imaging.

Radiology faces the third heaviest burden from prior authorization in Medicare Advantage, one study found. These burdensome utilization-management tactics can lead to care delays, anxiety and administrative burden for cancer patients, another analysis determined.

L.A. Care believes removing these codes will give physicians the flexibility to make “member-centric and medically appropriate decisions in a timely manner.” Certain services will always require PA, including inpatient-level care (excluding childbirth), clinical trials, transplant surgery, unlisted procedures/codes, and work provided by noncontract providers.

“L.A. Care is listening to providers who have said prior authorizations have led to adverse events in their patient care,” Baackes added. “We also understand prior authorizations have had an impact on physician burnout, when we are already facing a growing shortage of physicians who treat the most vulnerable populations that L.A. Care serves.”  

The health plan covers more than 1 of every 4 Angelenos, with its labels including Medi-Cal, L.A. Care Covered, L.A. Care Medicare Plus and the PASC-SEIU Homecare Workers Health Care Plan.