Payers Intensify Prior Authorization for Cardiology Imaging
Payers are expanding prior authorization and notification programs for advanced cardiology procedures, increasing the administrative burden on imaging providers. Companies like UnitedHealthcare are implementing these programs to ensure evidence-based utilization. While framed as a quality-control measure, these initiatives are largely viewed as cost-control tools that can delay patient care.
- According to a 2024 American Medical Association (AMA) survey, 93% of physicians reported that prior authorizations delay patient care, and more than a quarter (29%) stated these delays have led to a serious adverse event for a patient. Physicians and their staff spend an average of 13 hours per week completing nearly 39 prior authorization requests, contributing significantly to burnout. - The administrative burden of prior authorization is substantial, with physicians reporting their practices complete an average of 43 prior authorizations per physician each week. This process is not only time-consuming but also costly, with an estimated annual expense of $83,000 per practice. - There is a significant shift in cardiac imaging from physician offices to hospital outpatient departments (HOPDs). From 2010 to 2019, cardiologist in-office myocardial perfusion imaging rates dropped by 52%, while rates in HOPDs increased by 71%. Similarly, transthoracic echocardiograms performed by cardiologists in-office decreased by 23% as they rose 107% in HOPDs. - The use of coronary computed tomography angiography (CCTA) by radiologists in hospital outpatient settings grew by 355% between 2010 and 2019. Projections indicate that CCTA volumes are expected to grow another 24% over the next five years, driven by increased referrals from primary care and preventive cardiology. - Staffing shortages are a critical issue in radiology, with the vacancy rate for radiology technologists reaching 18.1%, a significant increase from 6.2% three years prior. The demand for imaging services continues to outpace the growth of the workforce, with CT and MRI scans increasing by 8% in 2024, while the radiologist workforce grew by only 4.2%. - Artificial intelligence is playing a growing role in cardiology and radiology, with over 1,000 AI algorithms cleared by the FDA for medical imaging. In the first half of 2024, cardiovascular AI accounted for 18% of all new AI device clearances when including imaging applications. Recent FDA approvals include AI software for detecting cardiac amyloidosis from echocardiograms and for automatically measuring coronary artery calcium from CT scans. - In response to provider feedback, some payers are reducing prior authorization requirements. In August 2023, Cigna removed prior authorization for over 600 medical services, and in November 2023, UnitedHealthcare eliminated some requirements for procedures in cardiology, radiology, and spine surgery. Cigna also ended pre-authorization for CPT code 75574 (CTA of the heart and coronary arteries) in most markets. - Legislative efforts are underway to streamline the prior authorization process, such as the "Improving Seniors' Timely Access to Care Act." This bipartisan bill would require Medicare Advantage plans to implement electronic prior authorization systems and establish standards to reduce delays in care.
