For select conditions, Aetna is introducing processes for authorizations that integrate pharmacy prescriptions and medical procedures into a single clinical review.
About six months after joining a pledge to reform prior authorization, Aetna announced it has begun bundling medical and pharmacy approvals for select conditions, stating that the goal is to reduce the administrative burden for providers.
For revenue cycle leaders accustomed to an adversarial relationship with payers, the move could suggest the payer is sincere in its effort to reduce friction in authorization processes.
Under the new model, if a primary medical service is approved, associated care components are automatically approved as well.
For now, bundled authorizations are only being used for musculoskeletal care and fertility services.
For instance, for a patient receiving a knee arthroscopy, a bundled authorization approval would include the procedure, X-rays, inpatient admission, DME, and medications. For fertility services, providers can submit one authorization for IVF procedures and for the requisite medications.
Is This a Win for the Voluntary Payer Pledge?
Earlier in the year, Aetna signed onto an agreement with around 40 other payers to voluntarily limit and simplify prior authorization. Revenue cycle leaders have viewed that move with cautious optimism. Earlier industry statements expressing similar intentions have not led to less administrative burden, which left providers skeptical.
However, the move to bundle authorizations could signal that the payer is trying to keep its commitment. By reducing the number of authorization requests, Aetna can claim a measure of success toward the goal of volume reduction
Will it Be Effective?
Unlike vague promises to "review and reduce" authorization lists, bundling is a structural change that targets fragmentation in single care episodes. For high-volume service lines like orthopedics and oncology, eliminating the need to receive separate approvals for DME or drugs removes bottlenecks where denials or delays often occur.
However, it remains to be seen whether Aetna will expand the practice, or if other payers will adopt similar processes. For the vast majority of claims outside these two specific episodes, the traditional PA process remains in place. It is also unclear how frequently manual reviews will occur if treatment plans deviate from those defined in Aetna’s bundles.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
Aetna has launched a new policy to bundle prior authorization requests for musculoskeletal care and fertility services.
The move allows providers to submit a single request that covers both the primary medical procedure and associated services like pharmacy or DME.
Revenue cycle leaders have expressed cautious optimism for payer-led efforts to reduce friction in authorization processes.