Private insurers are increasingly using prior authorization as a tool to keep people from getting needed care. Allison Bell reports for Think Advisor on what physicians are saying about the hoops they must jump through to ensure their patients’ care is covered. If you are enrolled in traditional Medicare, you do not have to worry about prior authorization rules; you and your physicians do not have to seek approval for care in advance of treatment. If you are enrolled in a Medicare Advantage plan, you might find that prior authorization rules make it harder for you to get needed care.
In a survey for the American Medical Association, one in three physicians do not believe that there is clinical validity to insurers’ prior authorization programs. The rules are virtually never or never based on medical society guidelines. One in 11 physicians say that these programs hurt patients. Nearly one in four physicians say patients often do not comply with medical guidance because of prior authorization rules.
Prior authorization rules are burdensome and time-consuming for physicians. They say that they typically have 40 procedures for which they need to secure prior authorization each week.
One big issue is that the insurers do not disclose the terms of their prior authorization programs. Because they are not open to public scrutiny, they can impose them without having to justify them. Moreover, they can impose them with little worry of a big expose on their lack of validity.
For sure, prior authorization requirements lower health care spending; they keep people from getting care. But, there is no comprehensive reliable evidence insurers can point to that shows that these requirements improve quality. Indeed, if you believe the physicians, they lower quality, delay care and force physicians to spend more time on paperwork that they could be spending with their patients.
Recently, CMS removed barriers to prior authorization in most federal programs, but not Medicare Advantage. It’s time to go the next step. Congress should either prohibit their use or require full disclosure and justification for each rule insurers use.
Here’s more from Just Care:
- CMS rule would make prior authorization easier for people in most federal programs, except Medicare Advantage
- Well-kept secrets of Medicare Advantage plans
- Medicare coverage changes for 2021
- The wrong choice of Medicare Advantage plan could kill you
- Seven reasons commercial insurance cannot meet our health care needs
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