Prior authorization: How dangerous is it?

Health insurers argue that requiring prior authorization before you receive certain services–approval for particular treatment–allows them to better manage your care. In fact, prior authorization requirements often lead health insurers to delay your receipt of care and can jeopardize your health. Traditional Medicare does not require prior authorization for medical services, but Medicare Advantage plans do, as do all commercial health insurers. What are the dangers of prior authorization?

Prior authorization requirements give health insurers the ability to come between you and your treating physician to decide whether the care your doctor recommends is medically reasonable and necessary. Too often, health insurers take their pretty time in deciding whether they will cover the care treating physicians recommend. And, if it’s a specialty procedure, the person deciding often has no specialty expertise. That health insurer employee might even have a financial incentive to delay or deny your care.

Lola Butcher reports for Medscape on one oncologist who believes prior authorization requirements resulted in the death of his patient. In that case, the health insurer refused to approve a PET scan when the oncologist initially sought authorization for it. The insurer came between this physician and his patient, delaying the patient’s care and allowing more time for the patient’s cancer to spread.

The oncologist fought the health insurer’s denial of the PET scan, insisting that it was standard care for a patient in his condition. During the more than three weeks it took the doctor to get the insurer to approve the procedure, the patient was hospitalized because his symptoms grew worse.

Unfortunately, inappropriate denials resulting from prior authorization are not uncommon. Inappropriate delays of three to four weeks or more while physicians argue with the health insurer, are also not uncommon. And, physicians say that insurers are using prior authorization requirements for medical procedures and prescription drugs more often.

There are two sides to the prior authorization story. Prior authorization could keep doctors who are not following standard protocols from providing improper treatments. But, do they do more harm than good?

To complicate matters, there’s no way to know what medical protocols health insurers are following when they deny coverage for a procedure. Unlike other countries that set the medical protocols for private health insurers, our government allows insurers’ medical protocols to be proprietary. Yet, these protocols can result in people not getting needed care in a timely manner. Health insurers have a financial incentive to delay and deny care inappropriately as the less money they spend on care the more they profit.

One doctor reports that he tried to prescribe a patient who had an infection the standard drug for the standard 10-14-day course of treatment. But, the insurer would only authorize the drug for five days, even though there is no data to suggest five days is adequate.

Another doctor reports that a patient of his needed an ultrasound and MRI twice a year to monitor her for breast cancer, as she was at high risk, testing positive for the BRCA gene and with a family history. But, the insurer has required him to get prior authorization each time his patient needs the procedures. This takes up a lot of his time for no legitimate reason. Her medical history is not changing.

The stories of inappropriate delays caused by prior authorization requirements are seemingly endless. And, they happen even when patients are in emergency situations. It’s not every health insurer, but reports suggest that it’s a significant proportion of them. People have no clue which health insurers to avoid.

Sometimes insurers require patients to get particular tests before they can get a procedure. The problem is that a negative test result might not indicate that the patient does not need the procedure. One specialist explains that the MSLT is often wrong as a measure for whether a patient suffers from narcolepsy. But, some insurers require it in place of the treating physicians’ expert opinion, undermining their patients’ care.

Appealing wrongful insurance company denials also can be extremely time-consuming.

Some states are finally intervening. Texas, for example, does not permit health insurers to require physicians to seek prior authorization if the physicians have met the insurers’ medical necessity criteria at least 90 percent of the time in the past six months. In Illinois, a new law limits the number of services for which insurers can require prior authorization and mandates that insurers make a determination within five days.

The US Congress is also considering bi-partisan legislation to protect people from some of the burdens of prior authorization. It focuses on limiting the use of prior authorization by Medicare Advantage plans and requiring Medicare Advantage plans to make real-time coverage decisions in certain cases, as well as to have an electronic prior authorization process.

Here’s more from Just Care:

• Well-kept secrets of Medicare Advantage plans
• Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
• People with serious health needs more likely to disenroll from Medicare Advantage plans
• Six reasons you need a primary care doctor in this age of specialization
• Do you need a geriatrician?