Blue Cross Blue Shield Of Massachusetts To Eliminate Prior Authorization For Home Health Discharges

Blue Cross Blue Shield of Massachusetts is getting rid of one of the biggest pain points for home health providers: prior authorization.

The change will eliminate more than 14,000 authorizations, according to the company. Broadly, patients being discharged from the hospital to home health care will not need advanced approval.

The types of care that will be impacted include physical therapy, occupational therapy, home health aide and nurse visits, and social worker visits.


BCBS of Massachusetts touted what it will do for hospitals and patients looking forward to discharge. But right up there with those two groups will be the home health providers on the receiving end of those discharges.

“We know from our clinical partners that local hospitals are experiencing a capacity crunch – we’re doing what we can to help,” BCBS of Massachusetts Chief Medical Officer Dr. Sandhya Rao told Home Health Care News in an email. “By removing prior authorization requirements for home care services, we’ll help hospitals to expedite discharges at a time when many are struggling with overcrowding. This change will also reduce delays for Blue Cross members ready to transition their care from hospital to home.”

Based in Boston, BCBS of Massachusetts is a nonprofit insurance provider with a wide variety of health plan offerings. Prior authorization requirements will be dropped for home health care in commercial plans by Jan. 1 of 2024 and for Medicare Advantage (MA) plans by 2025.


Rao said that dropping prior authorization in MA would have come in 2024 as well had it not been for government regulations that prevented BCBS of Massachusetts from doing so.

The company acknowledged the value of prior authorization, but did acknowledge that 98% of Blue Cross claims do not require it. Home-based care services, however, had long been part of that other 2% of services.

“This is a way for us to work with our clinical partners to ease administrative burdens and make the process smoother from end to end,” Rao said. “This will help streamline care delivery and remove administrative burden, allowing hospitals to discharge patients quicker and more efficiently. We see this as an all-around win – we’re helping to simplify the process for providers, patients and their families.”

BCBS of Massachusetts also recently removed prior authorization requirements elsewhere, such as select mental health services and continuous glucose monitoring devices for Type 1 diabetes.

Where prior authorization is still needed, the company is working on fast tracking it through automation.

Slowly but surely

Home health care providers’ biggest gripe with MA plans is generally the rates they pay for services.

But, right behind that is prior authorization, which can lead to extreme administrative burden for providers.

Intrepid USA Healthcare Services CEO John Kunysz is one of the provider leaders that has been very vocal about the prior authorization problem in home health care for years.

“The prior authorization process should be based upon the patient’s primary diagnosis and have a standard number of visit authorizations based upon evidence-based medicine. Care delayed is care denied,” he told HHCN last year.

Cigna (NYSE: CI) also announced that it would be shedding 25% of medical services from its prior authorization requirements earlier this year.

“Prior authorizations are an important step to ensure patient safety and affordability, but clinicians and health plans alike agree that more can be done to reduce the administrative burden on clinicians,” Cigna Healthcare CMO Scott Josephs said at the time. “We will continue to engage with clinicians to align on care delivery goals and outcomes and evaluate whether there are other changes we can make without compromising patient safety.”

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