JustCare

Tag: Prior authorization

  • How prior authorization requirements in Medicare Advantage could threaten your health

    How prior authorization requirements in Medicare Advantage could threaten your health

    If you’re in a Medicare Advantage plan and have needed any costly care, you likely know about prior authorization requirements that save corporate health insurers money but can threaten people’s health and well-being. Doctors say that many of these requirements are not evidence-based but, somehow, they are allowed. In an opinion piece for the AMA News, Gerald Harmon, MD, President of the AMA, describes how prior authorization “administrative hassles” could threaten your health.

    People in traditional Medicare do not have to deal with prior authorization requirements in order to get the care they need. If their doctor recommends a test or a specialty service, Medicare pays. In stark contrast, Medicare Advantage plans impose prior authorization requirements in a variety of situations, often harming patient health. AMA doctors surveyed reported incidents of preventable “hospitalization, disability and permanent bodily damage, or death” for patients they care for as a result of prior authorization requirements.

    Dr. Harmon writes about his attempt to get prior authorization for his 92-year old mother, which kept her from getting important drugs for an unknown period of time. He spent an hour trying to expedite approval of his mom’s prescriptions with no success. After trying to get help from a variety of folks, he turned to his mom’s doctor who took over the effort to get his mom the drugs she needed.

    Even with help from his mom’s doctor, there was no guarantee his mom’s insurer would authorize her drugs for several days. In turn, Dr. Harmon was deeply concerned about the deleterious effects on his mom’s health of not having needed medications. Note: Dr. Harmon was not concerned about drug copays–another enormous barrier to care–that leads to thousands of unnecessary deaths of people with Medicare each year.

    The AMA has an initiative to “fix” prior authorization requirements. For sure, prior authorization should either be eliminated or restricted to specific evidence-based situations when certain treatments might not be warranted. They should never prevent patients from getting timely access to needed care.

    The AMA supports bi-partisan legislation in Congress that would help people in Medicare Advantage plans, the Improving Seniors’ Timely Access to Care Act of 2021 (H.R. 3173/S.3018). It wouldn’t eliminate prior authorization, but it would simplify and standardize it.

    If you have stories about how prior authorization in Medicare Advantage kept you or someone you love from getting needed care, please send them to [email protected].

    Here’s more from Just Care:

  • Prior authorization in Medicare Advantage harms patients, sometimes severely

    Prior authorization in Medicare Advantage harms patients, sometimes severely

    MedPage Today reports on a poll finding that prior authorization requirements in managed care plans, such as Medicare Advantage, lead to patients needing hospitalization, becoming disabled or dying, according to one in three physicians. Why does Medicare allow prior authorization–with its often unjustified barriers to care–in Medicare Advantage plans?

    No one can deny that sometimes people get care that they don’t need. But, what makes health insurers able to determine what care is needed? On what do they base their decisions?

    As a general rule, health insurers are not held to account for their prior authorization policies. Yet, this AMA survey found that three in ten physicians say that health insurers rarely if ever use prior authorization criteria that is evidence-based. And, 91 percent of physicians say that insurer prior authorization criteria have a negative impact on their patients’ health outcomes.

    Almost one in five physicians (18 percent) said that an insurer’s prior authorization requirement resulted in a life-threatening event for a patient or a health outcome that “required intervention to prevent permanent impairment or damage.” On top of that one in 12 physicians said that their patients became disabled or physically harmed or died as a result of prior authorization requirements.

    Congresswoman Suzan DelBene of Washington State has a bill, Improving Seniors” Timely Access to Care Act, intended to standardize prior authorization programs in Medicare Advantage plans. It would require health plans to disclose their requirements and greater oversight of them.

    Some states limit or have introduced bills to limit insurers from using prior authorization, including New York, Texas, Illinois and Indiana.

    More than 1,000 practicing physicians completed the survey.

    Here’s more from Just Care:

     

  • Prior authorization: How dangerous is it?

    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:

  • The myths health insurers want you to believe

    The myths health insurers want you to believe

    When I was a health insurance communications exec, I was a big part of an ongoing effort–funded by your premium dollars–to get you to believe big myths about the U.S. healthcare system.

    Even a minute or two of Googling would have disproved our claims, but we succeeded because we knew most people wouldn’t bother. For the most part, health reform advocates have also not been up to the task of challenging the misinformation and setting the record straight.

    Why do my former colleagues keep this deception going? For a single reason: to protect what has become an extraordinarily profitable status for health insurers. As long as you (and the people you vote for) keep believing the myths, you will be parting with far more of your hard-earned dollars than you should to keep insurers’ shareholders happy.

    Let’s look at three of those myths.

    Myth 1: The U.S. has the best health care system in the world. 

    While there is no doubt we have some of the very best hospitals, technology, physicians and other caregivers, we are nowhere close to having the best system. My former colleagues and I perpetuated that myth because we wanted you to think that any kind of significant reform is unnecessary, especially if the reform might reduce insurance revenues and profits. We didn’t even want you to think that the millions of Americans without insurance is a big deal because, well, those are just people shirking their individual responsibility by remaining uninsured. In other words, it is their fault, not the system.

    In 2004, long before the Affordable Care Act was passed, the Commonwealth Fund launched a major project to assess the performance and fairness of several developed countries’ health systems. Of the 11 systems assessed, ours came in dead last. They have updated the assessments every couple of years, and the top-performing systems have varied over time, but one thing has remained constant: the U.S. continues to bring up the rear–despite the ACA.

    The Commonwealth Fund’s most recent assessment, published just this month, found that once again, the United States “trails far behind” other high-income countries on measures of health care affordability, access, administrative efficiency, equity, and outcomes. This is despite the fact that we spend far, far more of our GDP on health care than any other country on the planet.

    So yes, we do indeed have some of the world’s best health care providers, but they are off limits to millions of us, because of the fragmented nature of how we pay for care and the administrative burden and costs associated with world-leading inefficiencies on the payer side.

    Myth 2: Our employer-based system of health coverage works beautifully, and we can count on it to be there when we need it. 

    That myth was busted big time last year when we witnessed millions of Americans losing their coverage along with their jobs during the pandemic. The truth is that most people who have employer-sponsored insurance (ESI) are just a layoff or plant closing away from being plunged into the ranks of the uninsured.

    The insurance industry and its allies, including the U.S. Chamber of Commerce, which just published a commentary on its website extolling the virtues of ESI, have persuaded politicians on both sides of the aisle to remind us that more than 150 million Americans get their coverage through the workplace. What they don’t tell us is that that number hasn’t increased much at all over the past 20 years while the U.S. population has grown by more than 50 million.

    One big reason: fewer than a third of small U.S. businesses now offer coverage to their workers, compared to around half two decades ago. The average family policy through an employer has increased to more than $21,000 a year, according to the Kaiser Family Foundation, and the cost of insurance has gotten so high that more and more small employers are throwing in the towel.

    Even our biggest employers are now realizing that the cost of providing coverage to their workers is out of control. An astonishing 87% of the top executives of America’s largest companies say the cost of providing health insurance will become unsustainable for them in the next five to ten years, according to a survey conducted earlier this year by the Kaiser Family Foundation and the Purchaser Business Group on Health.

    Myth 3: Health insurers are appropriate and efficient gatekeepers to healthcare.

    Under the pretense of reducing unnecessary and inappropriate care, insurers began making providers get approval from them in advance before treating people enrolled in their health plans. But by putting increasingly aggressive prior authorization requirements in place, these policies also reduce access to care that is both necessary and appropriate, and insurers avoid paying an untold number of claims.

    Insurers have become so aggressive that one in four doctors say prior authorizations requirements have caused “serious adverse events” for their patients and in more than a few instances have contributed to premature patient deaths (according to the American Medical Association).

    Insurers have succeeded in persuading employers and policymakers that these prior authorization requirements save money, but there is little evidence to support that. In fact, prior authorization demands add considerably to the high administrative expenses the Commonwealth Fund and other researchers note are unique to the U.S. healthcare system.

    Ultimately, these myths serve to preserve the status quo. Insurers continue to bring in record profits, by making care harder to access. Perpetuating these myths are central to deflecting criticism and avoiding reform.

    This post was originally published on Un-covered.

    Here’s more from Just Care:

  • Insurers use prior authorization to keep people from getting care

    Insurers use prior authorization to keep people from getting care

    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

    CMS rule would make prior authorization easier for people in most federal programs, except Medicare Advantage

    People in Medicare Advantage plans–the private health insurance plans that offer Medicare benefits–contend with multiple challenges to getting care, including restricted networks of doctors, high deductibles and copays, and prior authorization rules. Healthcare Dive reports that the Centers for Medicare and Medicaid Services just issued a rule that would make prior authorization easier for people with Medicaid, people in state health insurance plans and people in the CHIP program beginning January 2023. For some incomprehensible reason, the rule does not apply to people in Medicare Advantage.

    As you might expect, the hospitals, doctors and patients generally like the proposed rule. It would standardize and speed up the approval process for the delivery of health care services and medicines, reducing the burden on them. It would means shorter delays in the delivery of care.

    But, the providers do not understand why it does not include Medicare Advantage plans. Why shouldn’t they be part of a CMS rule that standardizes data-sharing? They cover millions of people. Not having them included only complicates matters for providers and makes it harder for older adults and people with disabilities enrolled in Medicare Advantage to get care.

    What’s problematic about the new rule is that it gives health plans–except for health plans in the state health insurance exchanges–as long as seven days to make a decision about whether to authorize a standard procedure. Even when the procedure is urgent, the insurers have three full days.

    Why should health insurers have so much power to delay care and jeopardize people’s health, even in an urgent situation? The American Hospital Association has asked that the timelines be changed to three days in non-urgent situations and 24 hours in urgent cases.

    Health insurers, for their part, are not happy with the rule whatsoever. Prior authorization allows them to delay care. At times, it deters people from getting care altogether. Anytime that care is delayed or foregone, the insurers do not spend money and profit.

    The new policy also requires insurers to let hospitals and doctors know why they are denying authorization. The insurers complain that the burden is all on them.

    The health insurers don’t have much of an argument. They claim “distraction” from containing the pandemic. They also claim that the comment period is too short to enable them to comment appropriately. They say it violates the Administrative Procedures Act.

    It’s all hogwash, but that doesn’t mean that the health insurers won’t be able to wield their enormous power to undo the rule. The question is whether the health insurers are more powerful than the doctors, the hospitals and the patients. Most likely yes, since they have more resources.

    The rule would force more electronic interoperability among providers and insurers. For all kinds of reasons, the improved ability to exchange data is important.

    Here’s more from Just Care:

  • Do you need care? Why should your health insurer decide

    Do you need care? Why should your health insurer decide

    In a Washington Post op-ed, William E. Bennett Jr., a gastroenterologist and associate professor of pediatrics at the Indiana University School of Medicine, makes the case that health insurers should not be allowed to practice medicine. They too often deny medically necessary care unless and until your doctor is willing to go through hoops with their medical staff. But, medical staff who work for health insurers have no clue whether you need care.

    Bennett appreciates our need for health insurance. He also recognizes that having health insurance is necessary but not sufficient for our well-being. To get his patients needed medicines and tests, he must request prior authorization from his patients’ insurers, which can needlessly delay their access to care for weeks. And, still, the insurers may deny needed care.

    Only if Bennett appeals to a doctor who works for the insurer and says the right key phrases, will the insurer reverse its denial. Most of the time, the doctor in the employ of the health insurer has little accurate information about the patient; the doctor has never had any contact with the patient. Bennet explains that the insurer’s doctor is unqualified to know whether the treatment or medicine is needed.

    There is nothing beneficial about this process for the doctor or the patient. It does not assure the patient gets the proper treatment. In fact, it keeps many patients from getting needed care. And, it burdens the doctor excessively and unreasonably.

    Bennett experiences the system from the patient’s side as well because his daughter has a serious health condition, and he has had to deal with an insurer that has limited her access to needed treatment. Appealing is a challenging process that requires Bennett to rely on the advocacy of his daughter’s doctors. It takes time and does not always work. In the meantime, his daughter suffers, even though his daughter’s treating physicians all know she would benefit from the treatment.

    In short, when health insurer denials are based on the insurer’s claim of lack of medical necessity, the system breaks down, and the most vulnerable patients are harmed. One study revealed that one health insurer denied claims for emergency visits that met a “prudent layperson” emergency coverage standard in more than 85 percent of cases. Patients can appeal the denials with a high likelihood of success on appeal. But, only a tiny number know they can appeal and have the wherewithal to do so.

    Bennet concludes that health insurers should not be able to decide the care people need: “When an insurance company reflexively denies care and then makes it difficult to appeal that denial, it is making health-care decisions for patients. In other words, insurance officials are practicing medicine without accepting the professional, personal or legal liability that comes with the territory.”

    Here’s more from Just Care: