
Health insurers promise to improve coverage reviews that prompt delays and complaints
UnitedHealthcare, CVS Health's Aetna and dozens of other insurers say they plan to reduce the scope of health care claims subject to prior authorization, standardize parts of the process and expand responses done in real time.
Prior authorization means insurers require approval before they'll cover medical care, a prescription or a service like an imaging exam. Insurers say they do this to guard against care overuse and to make sure patients get the right treatment.
But doctors say the practice has grown in scope and complication, leading to frequent care delays. The fatal shooting of UnitedHealthcare CEO Brian Thompson in December prompted many people to vent their frustrations with coverage issues like prior authorization.
Dr. Mehmet Oz called prior the practice 'a pox on the system' that hikes administrative costs during his Senate confirmation hearing in March to lead the Centers for Medicare and Medicaid Services.
Insurers said Monday that they will standardize electronic prior authorization by the end of next year to help speed up the process. They will reduce the scope of claims subject to medical prior authorization, and they will honor the pre-approvals of a previous insurer for a window of time after someone switches plans.
They also plan to expand the number of real-time responses and ensure medical reviews are done for denied requests.
'We're sort of trapped between care being unaffordable and then these non-financial barriers and administrative burdens growing worse,' said Michael Anne Kyle, an assistant professor at the University of Pennsylvania who studies how patients access care.
Nearly all customers of Medicare Advantage plans, the privately run version of the federal government's Medicare program, need prior authorization for some services, particularly expensive care like hospital stays, the health policy research organization KFF found in a study of 2023 claims. The study also found that insurers denied about 6% of all requests.
Dr. Ashley Sumrall of Charlotte, North Carolina, says she has seen an increase in prior authorizations required for routine exams like MRIs. An oncologist who treats brain tumors, Sumrall said these images are critical for doctors to determine whether a treatment is working and to plan next steps.
Doctors say delays from requests that are eventually approved or coverage rejections can harm patients by giving a disease time to progress untreated. They also can spike anxiety in patients who want to know whether their tumor has stopped growing and if insurance will cover the scan.
'There's a term that we use called 'scanxiety,' and it's very real,' said Sumrall, a member of the Association for Clinical Oncology's volunteer leadership.
Different forms and varied prior authorization policies also complicate the process. Sumrall noted that every insurer 'has their own way of doing business.'
'For years, the companies have been unwilling to compromise, so I think any step in the direction of standardization is encouraging,' she said.
The insurers say their promises will apply to coverage through work or the individual market as well as Medicare Advantage plans and the state and federally funded Medicaid program.
Hashtags

Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles


Business Wire
2 minutes ago
- Business Wire
SimiTree Launches AI-Powered SARA for Faster, Smarter OASIS & Coding
HAMDEN, Conn.--(BUSINESS WIRE)--SimiTree, a provider of revenue cycle, coding, and consulting services for the post-acute and behavioral industries, today announced SARA (SimiTree Assessment Review AI), a proprietary artificial intelligence platform designed to improve clinical documentation review, coding accuracy, and operational efficiency for home health agencies. SimiTree is a portfolio company of Sheridan Capital Partners. 'SARA is the result of decades of clinical expertise combined with the analytical power of more than one million charts,' said Bill Simione, CEO and Managing Principal at SimiTree. 'It was designed and built by clinicians, for clinicians, enabling them to deliver smarter, faster and more accurate chart reviews. SARA redefines what is possible in coding and documentation support for home health.' Home health agencies are facing rising documentation demands, staffing shortages, increasing compliance pressures, and looming Medicare reimbursement cuts proposed for 2026. SARA – which is powered by one million charts to train AI-enabled large language models and supported by a team that has been providing coding and OASIS services for 15 years – combines expert human review with advanced AI to help agencies meet these challenges while lowering costs and improving outcomes. 'We built SARA to directly address the operational and financial pressures home health agencies face every day,' said David Berman, COO of SimiTree. 'SARA provides agencies with a scalable, intelligent solution that reduces administrative burden, accelerates turnaround times and delivers real-time coding and OASIS insights that drive better results.' SARA enables teams to return completed charts in less than half the time of traditional models while maintaining exceptional quality. The platform precisely identifies ICD‑10 primary and comorbidity codes, optimizes OASIS scoring, and flags inconsistencies before charts are finalized, reducing denials and boosting first‑pass acceptance rates. SARA is supported by SimiTree's quality assurance team of clinical nurses. 'OASIS assessments are the foundation of home health reimbursement and outcomes measures, yet they remain one of the most complex and error-prone assessment tools in healthcare,' said J'non Griffin, SVP Coding and OASIS/Compliance at SimiTree. 'SARA brings AI precision to OASIS and coding, improving patient assessment accuracy and optimizing reimbursement outcomes.' Unlike typical software rollouts, SimiTree's service requires no infrastructure or staff onboarding, allowing agencies to see results immediately and redirect resources toward growth and patient care. About SimiTree SimiTree, a Sheridan Capital Partners portfolio company, is a leading provider of tech enabled, specialty revenue cycle management, coding, consulting, staffing solutions and managed services for home health, hospice and behavioral health organizations. By combining deep domain expertise with innovative technology, SimiTree helps providers optimize operations, ensure compliance, and achieve sustainable growth. For more information, visit About Sheridan Capital Partners Sheridan Capital Partners is a Chicago-based healthcare private equity firm that focuses on lower middle market buyouts and growth equity in the U.S. and Canada. Sheridan partners with companies in the verticals of providers and provider services, healthcare IT and outsourced services, and consumer health and medical products, and strives to bring strategic resources to accelerate growth, build enduring value, and achieve strong results. For more information, please visit


Axios
an hour ago
- Axios
This Medicare change is giving hospitals heartburn
Hospitals found an unpleasant surprise buried in a proposed 913-page Medicare payment rule last week: a Trump administration plan to speed up — by a decade — the recovery of $7.8 billion in improper cuts to facilities' discount drug reimbursement. Why it matters: The change comes out to over $1 billion less than expected in Medicare payment next year, with more reductions going forward. Reduced Medicare payment would be a double whammy, hitting just as sweeping changes to Medicaid are expected to put new financial pressures on facilities. "It's piling on," Maureen Testoni, CEO of 340B Health, which advocates on behalf of hospitals that participate in the discount drug program, told Axios. Facilities that rely on these federal programs are "definitely going to reach unsustainability." Some industry groups are already threatening to sue to halt the plan if it's finalized, saying it punishes hospitals for a mistake that Medicare itself made between 2018 and 2022. The new timeline for clawbacks would jeopardize hospitals' ability to care for patients in need, Testoni said in a statement. Follow the money: The clawback stems from a Supreme Court ruling that overturned a nearly 30% cut the first Trump administration made in payments to safety-net providers in the 340B federal discount drug program, after research showed some could profit inappropriately off the program. Medicare repaid $9 billion to make the affected hospitals whole early last year. The problem was that Medicare budgeting anticipated future savings from the 30% cut boosted pay for hospital outpatient services other than dispensing drugs. To avoid adding to total Medicare spending, the Biden administration devised a plan to claw back $7.8 billion in increased reimbursements from hospitals over 16 years. Now, the administration wants to reduce that timeline by a decade, arguing the quicker process would make the burden on hospitals more closely reflect the benefits they previously received. A more drawn-out process could also be complicated by hospital closures, it said. That translates into a bigger annual clawback for hospitals already operating on tight margins. The Centers for Medicare and Medicaid Services also notified hospitals last week that it plans to conduct a survey early next year on their costs for acquiring drugs, including rebates and discounts that hospitals receive under the federal 340B discount drug program. The notice doesn't explicitly say that the survey will be used to justify future cuts to hospitals' reimbursement. But industry executives say that's the subtext, especially in light of the 2022 Supreme Court decision. Between the lines: Hospital participation in 340B has grown significantly over the past two decades. Nonprofit and public hospitals that qualify for the program say it enables them to provide charity care. But critics say it's gotten too big and charge that some hospitals abuse the program. Conservative think tanks that have the Trump administration's ear, like Paragon Health Institute, have recommended overhauling the way Medicare pays for discounted drugs. What they're saying: The American Hospital Association hinted it could sue the administration if it moves forward with accelerated clawbacks. "The proposed recoupment is both illegal and unwise, and it should not be finalized," Ashley Thompson, AHA's senior vice president of public policy analysis and development, said in a statement. The Association of American Medical Colleges also said that speeding up the clawbacks "will have catastrophic effects on patients nationwide." What to watch:"We expect significant pushback in the comments to this proposed rule and that the final rule may be less aggressive," Chris Meekins, managing director at Raymond James and health official in the first Trump administration, wrote in an analyst note.


Time Business News
16 hours ago
- Time Business News
Imaging Boom Drives Cancer Detection and Healthcare Growth
Cancer is a condition where cells in a specific part of the body start multiplying out of control, often clumping together to form tumors. Doctors can identify cancer using different kinds of tests, including imaging scans, endoscopy, tumor marker tests, biopsies, complete blood counts, and MRI scans. Major growth factor consist of large number of clinics have adopted tools for cancer detection like MRI, CT-scans and other. This has led to growth in healthcare sector and global economy. It is also a milestone for healthcare services. Key Growth Drivers and Opportunities Growing Incidence of Cancer: The increasing prevalence and incidences of various types of cancer like lung cancer and breast cancer, help the cancer diagnostics market to grow significantly during the forecast period. According to estimates, 1 in 100 (or 1% yearly) of those 70 years of age or over lost their lives to cancer in 2019. Overall death toll is rising in tandem with the world's population growth. From roughly 46 million in 1990 to 56 million in 2019, there have been more fatalities. Most cancer deaths occur in elderly adults. Rising Expenditure of Healthcare: The cost estimates cover both prescription medications taken by mouth and medical treatments for cancer. The most expensive medical services nationally were linked to non-Hodgkin lymphomas, as well as cancers of the prostate, lung, colon, and female breast. Medical services care costs, which comprise Medicare payments as well as patient obligations for all billed medical services, such as hospitalizations, outpatient hospital services, physician/supplier services, infusion or injectable drug, durable medical equipment, and hospice care, were estimated from Medicare Parts A and B claims. Challenges The implementing cancer diagnostics can require significant upfront investment, including the cost of the software itself, customization, and integration with existing systems. This can be a barrier for smaller hospitals with limited budgets. The regulatory landscape for cancer diagnostics is constantly evolving, with new guidelines and requirements emerging regularly. Keeping up with these changes and adjusting reporting practices accordingly can be a daunting task for companies Innovation and Expansion Guardant, Boehringer Team Up on HER2 NSCLC Liquid Biopsy In December 2024, the Guardant Health, Inc. announced a partnership with Boehringer Ingelheim aimed at obtaining regulatory approval and advancing the commercialization of the Guardant360 CDx liquid biopsy. This partnership is all about using liquid biopsy as a companion diagnostic (CDx) for zongertinib. Zongertinib is a new type of drug called a covalent tyrosine kinase inhibitor (TKI) designed to specifically target HER2 in non-small cell lung cancer (NSCLC), while minimizing the impct on the epidermal growth factor receptor (EGFR). GE, GenesisCare Partner to Tackle Cancer and Heart Disease In November 2020, GE Healthcare entered into partnership with GenesisCare to improve patient outcomes for the two biggest health burdens globally, cancer and heart disease. GE Healthcare will provide CT, MRI, PET/CT, SPECT, digital mammography, and ultrasound equipment to GenesisCare's 440+ cancer and cardiovascular disease treatment centers across Australia, the US, the UK, and Spain This partnership is all about boosting how accurately we can diagnose conditions and making treatment plans smoother, all thanks to state-of-the-art imaging tech. With GE Healthcare's innovative tools, GenesisCare can really speed up spotting issues early on and providing tailored care for folks dealing with cancer or heart-related conditions. Inventive Sparks, Expanding Markets The Key players in the global cancer diagnostics market includes, Thermo Fisher Scientific Inc., Hoffmann-La Roche Ltd., Abbott Laboratories, Becton, Dickinson and Company among others. As major key players, they're effectively striving in innovation to make sure consumers globally can benefit from modern healthcare tech and to really elevate the overall experience for patients everywhere. About Author: Prophecy is a specialized market research, analytics, marketing and business strategy, and solutions company that offer strategic and tactical support to clients for making well-informed business decisions and to identify and achieve high value opportunities in the target business area. Also, we help our client to address business challenges and provide best possible solutions to overcome them and transform their business. TIME BUSINESS NEWS