Annals urges standardized prior-auth database

Stanford University researchers say a new Annals of Internal Medicine report found major differences in prior-authorization rules across three large commercial insurers, despite prior authorization being a routine gatekeeping step for tests and treatments. The report reviewed public provider manuals from Aetna, Humana and UnitedHealthcare and concluded that the rules could be assembled into a shared searchable database. (e3.eurekalert.org) The authors said the current variation adds administrative burden for clinicians and confusion for patients. The paper was published on May 18 in Annals of Internal Medicine. ### Which insurers did the researchers compare? Aetna, Humana and UnitedHealthcare were the three insurers examined in the report. (medicalxpress.com) The researchers used publicly available provider manuals from those companies to compare when prior authorization was required and what documentation clinicians had to submit for approval of a test or treatment. Stanford University and colleagues conducted the work as part of a broader research program on the possible benefits of standardizing healthcare contracts, according to the report summary released by the American College of Physicians. Corresponding author David Scheinker, Ph.D., was identified in the release. (e3.eurekalert.org) ### What did the study actually find in those manuals? The researchers reviewed thousands of procedure and service codes and used a combination of automated review and manual checks to build a searchable database of insurer rules. They then used that database to compare how the three insurers handled prior authorization. (e3.eurekalert.org) The report found that all three insurers required prior authorization for some services, but that the majority of services requiring prior authorization were flagged by only one of the three insurers. It also found that the criteria and documentation requirements differed widely across insurers. (e3.eurekalert.org) ### Why are the authors calling for a national database? The authors said assembling the rules into a shared database was feasible and could improve transparency for both patients and clinicians. In the summaries released with the paper, they compared the idea to a single searchable system “like the ICD-10 system,” referring to the coding framework used across U.S. healthcare. (e3.eurekalert.org) The report did not say that insurers had agreed to adopt such a database. Instead, the authors said the unexplained differences across insurers warranted further research into whether this administrative barrier is appropriate for interventions ordered by clinicians. (e3.eurekalert.org) ### How does this fit with other prior-authorization changes this year? On April 24, UnitedHealth and CVS Health said they had standardized data and submission requirements for more than half of their prior authorizations as part of a broader industry effort to reduce delays and paperwork. UnitedHealthcare said more than 70% of requests would be part of that standardized process by the end of 2026, while CVS Health said Aetna had standardized 88% of its prior-authorization volume. (e3.eurekalert.org) Reuters reported that those insurer changes would apply to commonly reviewed medical services such as orthopedic surgeries, CT scans and MRIs, but would not change coverage rules or the medical reasons used to approve or deny care. (e3.eurekalert.org) That distinction matters because the Annals paper focused on variation in the rules themselves across insurers, not just on the format used to submit requests. ### Where can readers find the report next? Annals of Internal Medicine listed the paper as “Variation in Commercial Insurer Prior Authorization Rules,” with DOI 10.7326/ANNALS-25-05289. The American College of Physicians released a summary on May 18, and Annals of Internal Medicine promoted the findings on X the same day. (usnews.com) (e3.eurekalert.org)