Our federal government now requires health insurers in Medicare Advantage as well as select others to disclose the frequency with which they deny care through their prior authorization process as well as the frequency with which those denials are overturned on appeal. The Centers for Medicare and Medicaid Services, which oversees Medicare, is releasing this information so that people can see the data. But, will people get the whole story? Jakob Emerson reports for Becker’s Hospital Review.
The data is critical for people to see. Some insurers deny care 25 percent of the time. And, in many cases, those denials are overturned seven out of ten times or more on appeal. But, we need more data to understand which services insurers are denying and how many times they are doing so.
The data does not cover prescription drugs. It also does not allow people to compare Medicare Advantage plans and other insurance plans. And, it doesn’t give a count, only a percentage. Insurers covering people in the employer group market are not required to disclose their data.
What we do know is that insurers’ denial rates vary tremendously. And, few people appeal their denials. They give up when they can’t get their care covered likely because they don’t appreciate how easy it is to appeal and how likely they are to win on appeal.
Patrick Quigley, CEO of Sidecar Health, hits the nail on the head when he says about the prior authorization process: “We are creating massive amounts of waste in our system, and we are controlling cost within the system simply by denying care,”
The American Economic Liberties Project gets it right in its policy brief arguing that prior authorization, as it currently operates, should be banned. It is a tool for insurers to override treating physicians and, by so doing, increase their profits. It hurts patients. And, it costs clinicians and physicians as much as an estimated $32.7 billion a year.
Here’s more from Just Care:
- Oncologists report excessive deaths from prior authorization
- Prior authorization in Medicare Advantage harms patients, sometimes severely
- Insurers misuse prior authorization even for simple treatments
- Is there a good alternative to prior authorization?
- Congress proposes reforms to ensure timely access to care in Medicare Advantage
