Lauren Sausser reports for KFF Health News on the failure of the Centers for Medicare and Medicaid Services to protect people enrolled in Medicare Advantage plans from prior authorization rules that lead to inappropriate denials and delays of care and endanger their health and well-being. For those of you who don’t quite understand “prior authorization,” it is a process that allows health insurers to second-guess treating physicians, delay or deny coverage for your care before you receive it, and it is pure hell if you need care quickly. Because insurers profit more the more prior authorization they require, they use it without justification.
Like patients, doctors do not like prior authorization rules. These rules allow the insurers to overrule them, even when the insurers know little about patient needs. Prior authorization rules often require doctors to submit additional paperwork and evidence of the need for care, making it costly and resource intensive for the doctor to deliver the care that is needed.
Back in 2021, Medicare data reveal 1.5 prior authorization requests for each Medicare Advantage enrollee. When you consider that about half the Medicare population uses few or no services and 10 percent are responsible for 70 percent of services, we’re talking a lot of prior authorization hurdles to surmount for the people who most need care.
Congress can’t seem to get its act together to pass helpful legislation on prior authorization. At the very least, prior authorization rules should be public and evidence-based. Truly they should be consistent across all Medicare Advantage plans. Otherwise, how can people distinguish among the MA plans that require prior authorization and those that do not?
Right now, CMS is considering a proposed prior authorization rule that could help streamline and expedite the prior authorization process for people in Medicare Advantage, Medicaid or a state health insurance exchange. It would automate prior authorization, require insurers to make prior authorization decisions more quickly and explain the reason for their denials.
But, CMS has yet to act on its proposed rule even though the comment period ended last fall. Moreover, its proposed rule really does not go far enough. The American Medical Association agrees, as does the AHA. Congress is going to need to step in.
The insurance industry hides behind a lame rationale for prior authorization–ensuring enrollees get the care they need when they need it. In fact, prior authorization prevents just that. If the rationale for insurance provider networks is to ensure good care, insurers should not be second-guessing network providers.
Of course, prior authorization takes its biggest toll on the most vulnerable people with Medicare, who struggle to navigate the process and who most need care urgently. Sometimes it takes weeks or months to get insurance company approvals for care.
To ensure good access to needed care for people with Medicare, the government should standardize the prior authorization process across all Medicare Advantage plans and permit only evidence-based use of prior authorization. At the very least, it should implement an electronic process for prior authorization; physicians and patients should not have to be spending precious time on the phone trying to get approval for needed care.
Here’s more from Just Care:
- Medicare Advantage plans denied two million prior authorization requests in 2021
- UnitedHealth’s denials of critical rehab services is under investigation
- Government proposes to improve prior authorization process
- OIG finds widespread inappropriate care denials in Medicare Advantage
- How prior authorization requirements in Medicare Advantage could threaten your health
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