Doctors and patients raise alarm about prior authorization
Have you experienced the anxiety of getting a notice from your insurance company that a treatment, drug, or test your doctor ordered has been denied?
If you have private insurance, chances are you have, and you know that regardless of how sick you are, you’ve got to somehow muster enough strength to go to battle with Big Insurance. For many of us – including the retired teachers, EMTs, firefighters, and cops in New York City – it’s a life-or-death fight.
If you haven’t been denied coverage for something your doctor says you need, chances are you will if your health takes a turn for the worse, whether you get your coverage through an employer, the individual health insurance market, or a private Medicare replacement plan known as Medicare Advantage. Prior authorization is at the heart of the massive – and so far successful – opposition that has taken shape among NYC retirees to Mayor Eric Adams’ proposal to force all of them into an Aetna-owned Medicare Advantage plan. (Denials of medically necessary care are largely unknown in traditional Medicare.)
Many studies have documented a continuing increase in the use of “prior authorization” requirements. The American Medical Association has been raising the alarm about the increase for years and pleading with Congress and the Center for Medicare and Medicaid Services to intervene. The AMA’s research, including annual surveys of doctors, documents the harm prior authorization demands can cause patients. Its most recent survey of its members showed that:
91% reported that prior authorization can lead to negative clinical outcomes
82% said prior authorization can lead to patients abandoning their course of treatment
34% said prior authorization has led to a serious adverse event for a patient in their care
As Gerald E. Harmon, MD, immediate past president of the AMA was recently quoted in Medical Economics:
“Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health. Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”
Big Insurance, according to the AMA, has not worked with doctors in good faith to reform the prior authorization process, despite assurances from the industry. No surprise there. Prior authorization not only enables insurers to avoid paying claims, but it has also become a new source of profits for insurers and the vendors that have sprung up to analyze treatment requests from doctors and hospitals.
In the coming days, I’ll share the first of an ongoing series of stories about how prior auth is affecting patients, delaying or denying coverage for often life-saving care and, sadly, sending many Americans to an early grave. If you have stories of your own, please share them with us.
AND stay tuned for an industry insider’s account of how the prior authorization process really works.
An acquaintance recently had a really bad experience with prior authorization. His health has steadily deteriorated since a diagnosis in 2020. He went in for a biopsy, which went south. He was under anesthesia and was transferred to ICU. The insurance refused to pay for the $16k ICU stay because it wasn’t pre-reapproved. How was he supposed to get it pre-approved while unconscious and in a dire situation? The kicker? This guy is a doctor and knows how to navigate the "health" care system.
My favorite story about this and health insurance nonsense: transcranial magnetic stimulation for treatment Resistant depression is an FDA approved treatment. It’s been approved since 2008. The FDA label says one failed medication trial is the definition of treatment resistance. The payers have used 4 failed medication trials and to fail psychotherapy trials in the current episode, because this was the average number present in the FDA approval trial in 2008. Keep in mind there have been 4000 study since that time. They’re having multiple other FDA approvals across multiple other indications and multiple other protocols on multiple devices using brain stimulation with this approach. It is the safest and most effective treatment that has ever existed for depression. I submitted an appeal after a prior authorization for the treatment denied care for someone who would only failed one medication trial, but did not wish to take three more medication’s that wouldn’t work for months to years before they could get access to this treatment. It went to external appeal in the state of New York, and a board of three independent medical reviewers found it to be medically necessary. A complaint was placed with the state Attorney General about the process of unnecessary medical review. External medical reviewers concurred with my medical opinion, and found that united healthcare had no right to deny this treatment on appeal. Traditionally, when this happens and you have an attorney, general complaint from the patient along with it, the health payer is forced to pay for it ever onward--they’re external medical review which is independent trumps their internal medical reviewers, and when the Attorney General has a complaint, then enforce it. So, here is what united healthcare did next: they started denying my right to even place an appeal in the first place. I actually had to go to the courthouse to appeal my right to have an appeal. They knew if I got the appeal, I would automatically win, because external medical review had already deemed it medically necessary. And yet they continue to denying my right to appeal, and just not paying.
There is no winning, because there is no accountability. There are no criminal penalties for “healthcare” executives who pursue policies that violate both the corporate practice of medicine and medical ethics. Until that is the case, they will continue doing it. There is no such thing as a real financial penalty for United healthcare, it’s simply increases the cost of doing business, which increases the amount of money they can make.
Expect the nonsense to continue, until we end it.