Joyce Frieden reports for MedPageToday on Senator Sheldon Whitehouse’s proposal to address unseemly and inappropriate use of prior authorization by insurers offering Medicare Advantage plans. Senator Whitehouse wants insurers to get pre-approval from the government before it uses prior authorization for a procedure. Why shouldn’t that be the rule?
The alleged reason for the use of prior authorization is to ensure that a procedure is warranted before a patient receives it. If there’s a reason to question the treating physician, it should be evidence-based. And, if it is evidence-based, it should be generally accepted and approved.
There’s no reason to allow insurers to decide for themselves when and how to second-guess treating physicians. To the contrary, we know that insurers are using prior authorization to delay and deny care in some or many instances without any medical justification for so doing. Why should they be able to claim their prior authorization rules are proprietary and hide them from public scrutiny?
“There is no logic to prior authorization,” says Whitehouse, who chairs the Senate Budget Committee. He is absolutely correct. Prior authorization care delays can be harmful or even deadly. Prior authorization also imposes huge administrative burdens on physicians and their staff. Whitehouse proposes “No prior authorization without prior authorization,” from the government.
Whitehouse wants standardization of prior authorization rules. How we do not have standardized prior authorization rules in place already is the question. Each insurer uses different procedures and rules with prior authorization, driving up administrative costs to $200 billion each year.
Whitehouse echoed the HHS Surgeon General, who issued a report on worker burnout two years ago. The report did not call on the government to standardize prior authorization, as it should have. But, it did ask insurers to lower prior authorization requirements. To be clear, prior authorization is one way that insurers maximize profits, so voluntary action is no solution here.
Whitehouse wants the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, to set prior authorization standards that apply to Accountable Care Organizations in traditional Medicare and Medicare Advantage plans. We should all be calling for standardization.
CMS should also be doing more to standardize the use of artificial intelligence (AI).
Republicans, such as Senator Ron Johnson of Wisconsin, on the Senate Budget Committee think a better way to go is to make people pay more for their care. That’s a sure way to keep millions of vulnerable Americans from getting critical care. Johnson argues that the system is forcing doctors to stop taking insurance.
Here’s more from Just Care:
- Cigna medical directors given little incentive to review prior authorization denials thoroughly
- Medicare Advantage plans denied two million prior authorization requests in 2021
- How prior authorization requirements in Medicare Advantage could threaten your health
- Prior authorization in Medicare Advantage harms patients, sometimes severely
- Medicare Part D plans can make it hard to get prescription drugs
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