Removing prior authorization for some specialty visits

Jan. 29, 2024

Kaiser Permanente Washington is always working to improve how we integrate our care and coverage model for a better member experience. We hear from members, providers, and customers that our current practice of requiring prior authorization for specialty office visits creates administrative burdendissatisfaction, and potential delays in care for our patients.

In response to this feedbackwe decided to pilot the removal of prior authorization requirements for a select group of in-network specialty office visits for commercial and Medicare HMO members. By doing a pilot, we can allow time to assess the impact of the change – including improved member and provider satisfaction, reduced administrative time, and increased utilization and costs in the external delivery system (EDS). We plan a formal assessment of the pilot at 3 months and again at 6 months.

For perspective, we process more than 700,000 requests for EDS specialty office visit referrals/authorizations per year – with a 96% approval rate. Most denials occur for out-of-network provider requests and non-covered service requests.

We will still encourage referrals

We will continue to use our existing process for specialty referrals from our KP providers. In keeping with our KP model of care and philosophy, we will strongly encourage referrals for providers in our network. Claims will not deny for lack of a referral when that visit occurs with the group of network specialty clinicians that we identify as part of the pilot.

Please see this FAQ for more information.

All carrier plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. Self-funded health benefits are insured by an employer, union, or Plan sponsor. Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington, Inc., provide certain administrative services for the self-funded Plan and are not an insurer of the Plan or financially liable for health care benefits under the Plan.

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