One big insurer, Anthem, denied coverage inappropriately to a woman who needed medicine to ward off Lyme disease on the ground that she failed to get prior authorization for her care. Even when the care needed is simple and easy and patients use network providers, insurers will inappropriately refuse to cover care, putting patients at risk, reports Lauren Sausser for the Washington Post. Insurers have no basis for requiring prior authorization for primary care visits.
In this case, the patient with a tick bite scheduled an appointment with an in-network primary care physician after her in-network telehealth provider recommended she do so. Thankfully, she did. It was only because she visited the physician’s clinic that she learned she had another tick on her body that could have given her Lyme disease.
Still, Anthem, her insurer, refused to pay for her visit to the clinic. The insurer’s reason: She did not have a proper referral or authorization from her insurer to visit the clinic. Even with simple, low-cost medically necessary procedures–procedures that could be life-saving–insurers use prior authorization as a profit-maximizing strategy at a huge cost to their enrollees.
Corporate health Insurers had said that they were voluntarily going to change the prior authorization process to make it less burdensome for patients. A lot of good that did. Centers for Medicare and Medicaid Services (CMS) chief, Mehmet Oz, had said his team was going to improve prior authorization as well, but little has changed as of yet.
CMS is supposed to create a list of services for which prior authorization is no longer necessary, as of January 2026. CMS will list services which patients can obtain and, for which they will be covered, without approval from their insurers. If insurers refuse to cover these services, CMS has said it will hold them accountable, but it is unclear how.
As of yet, insurers have not said what aspects of prior authorization they are committed to changing effective January 1. And, for reasons that make a mockery of the insurers’ care management abilities, insurers say that they cannot commit to responding to prior authorization requests in real time until 2027. Why not?
The insurers promised to improve prior authorization as far back as 2018, the president of the American Medical Association reminds us, without making any meaningful reforms. Some experts, including yours truly, do not believe that we will see any meaningful fixes going forward. The government never seems to hold insurers accountable for these types of bad acts, even when they can cause patients serious harm and, at times, premature death.
The Anthem patient with tick bites appealed her coverage denial–which is always worth doing–after getting a retroactive referral from her primary care doctor. But, for unknown reasons, the patient did not prevail on appeal.
Several months later, after a reporter had intervened, Anthem reimbursed the patient $238, the full cost of the visit. Anthem attributed the inappropriate denial to a “billing error” by the patient’s clinic, which the insurer said it interpreted as a specialist visit. Primary care visits do not require a referral.
Here’s more from Just Care:
- How prior authorization requirements in Medicare Advantage could threaten your health
- Prior authorization in Medicare Advantage harms patients, sometimes severely
- Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans
- Is there a good alternative to prior authorization?
- Medicare agency to test prior authorization in traditional Medicare
