Twenty-Four Percent of Medical Codes Removed from the Health Plan’s Prior Authorization Matrix
LOS ANGELES – L.A. Care Health Plan, the largest publicly operated health plan in the country, is proud to announce that is has updated its list of codes requiring Prior Authorization, significantly reducing the number of services that require authorization. The health plan removed 24 percent of existing codes, which will help avoid delays in member care, speed up discharge requests, and decrease the administrative burden for providers. L.A. Care identified codes to remove from the matrix after conducting 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,” said John Baackes, L.A. Care CEO. “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.”
Examples of medical services that no longer require a Prior Authorization include:
• Most specialty care office visits, such as cardiology, nephrology, dermatology
• More than 50% of all laboratory test and radiology codes
• Durable medical equipment, such as crutches, walkers, standard wheelchairs
• Catheter supplies
By removing these codes, it gives physicians the flexibility to make member-centric and medically appropriate decisions in a timely manner.
“L.A. Care is listening to providers who have said Prior Authorizations have led to adverse events in their patient care,” said Baackes. “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 informed its providers of the changes, and also let them know that some services will always require authorization. These include:
• Inpatient Level of Care (excluding admissions for the birth of a child)
• Clinical Trials
• Transplant Surgery
• Unlisted Procedures/Codes
• Non-Contract Providers (other than those providing dialysis)
These rules apply in all instances where L.A. Care holds the financial responsibility to pay the claim.
L.A. Care kicked off a bi-monthly provider webinar series early this year to help educate providers on the health plan’s processes, available services, and important services. The health plan wants to be a true partner to its providers to ensure its members are able to count on the high quality care they deserve.