A new Biden administration rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments.
Prior authorization is a common tool used by insurers but much maligned by doctors and patients, who say it’s often used to deny doctor-recommended care.
Under the final rule from the Centers for Medicare and Medicaid Services, health insurers participating in Medicare Advantage, Medicaid or the ObamaCare exchanges will need to respond to expedited prior authorization requests within 72 hours, and standard requests within seven calendar days.
The rule requires all impacted payers to include a specific reason for denying a prior authorization request. They will also be required to publicly report prior authorization metrics.
the madness that is US “healthcare” never ceases to amaze me.
Know what happens when a doctor recommends me a treatment? I get that treatment.
I don’t have to hope an insurance company will “approve” of me getting that treatment. I don’t have to worry about paying for it.
Anyone still defending this system needs psychological help. Which would be denied by the insurance company. And cost 10000s out of pocket
It gets better. So many times Dr’s will have to start with treatments they know won’t work because otherwise insurance will just decline it all together.
The funny part is that this the ends up costing the insurance companies more. Nose removed, face spited.
It may cost more for that individual, which is likely additive. What’s multiplicative is the number of people who don’t or can’t jump through the hoops and just move on. Having a tough time getting out of a subscription service? Insurance basically did it first.
Agreed, they play the numbers game but at the cost of human suffering. All the cases where it costs them more though is just illustrative of the stupidity of it and helps show that there is room for legislation to curb this.
Anyone still defending this system needs psychological help. Which would be denied by the insurance company. And cost 10000s out of pocket
Approximately half the country supports it because it hurts people they don’t like, and they’re about to elect a literal dictator. Please send help
What country do you live in?
LPT: If your doctor firmly believes that you require X treatment/medication/etc. Have them use the specific term “medically necessary”. If your insurer kicks it back with that phrasing attached, contact them. Ask for the medical license number of the doctor who indicated that it was not medically necessary. Push for this information (they won’t have it) and continue the line of “Someone on your end is making a medical decision against my doctors orders. I require their credentials so I can confirm they are a) qualified to make medical decisions, and b) have a higher education that my doctor possesses.”
I’ll be interested if someone actually tried this
I speak from experience. Blue Cross has not argued or denied any of our doctors’ requests since the second time I used that method.
Had a specialist tell my wife she needed a shoulder replacement. Insurance wanted her to do physical therapy. I was livid. “I want the license number of the doctor on your end who is deciding that physical therapy is going to some how magically fix torn rotator cuff tendons. Telling our medical specialist that physical therapy is required is a medical decision that contradicts their diagnosis that it needs replaced. If we follow your recommendation and it fails, I need the name and license number of who to go after for making that decision. Shielding this professional, and I use that term loosely, indicates that you’re willing to assume all the liability when “physical therapy” causes more pain and damage.”Did they ever give you a license number, or did they just cave?
Said they’d have to “look into it”. Called back 20 minutes later to inform that they decided to approve the procedure.
It’s nonsense. For one, what is required for a treatment is handled by CMS and the CPT code itself, so the necessary documentation is either there or it isn’t and adding “medically necessary” doesn’t change a damn thing. Secondly, the commercial payors go by their own schedules for what is always, is never, and can be “medically necessary,” “experimental,” “diagnostic-only,” and a ton more. If your orthopedic surgeon is calling for a prior auth for a total knee replacement, it’s always medically necessary; peripheral vein ablation, it’s sometimes medically necessary; chin implant, never necessary.
Then I’m full of shit and my wife’s reverse shoulder joint is a figment of our collective imaginations.
“medically necessary” I think is just one of the descriptive words surrounding the language of the laws and forms. Its actually one of a number of phrases that should work as I’m pretty sure I’ve had a couple without it. Realistically any challenge that requires the insurance company to actually get a doctor to review a case should get a successful prior auth.
It’s not one or the other. You’re full of shit and your wife would have gotten her reverse total joint surgery regardless.
Insurers are known to automatically deny procedures based on what is essentially a flow chart (illegal) rather than a medical professional review of the case (required by law). This is why most insurers back down when a prior authorization is requested.
The whole process is being abused by insurers and if you ask doctors, nurses, pharmacists they’ll tell you the process is being abused.
Cigna got caught doing it https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims I guarantee you that most other insurance companies are doing this as well.
Insurance companies are going to do anything they can to reduce loss ratio, but… That is literally the plot of a John Grisham novel (pre-ACA, so it was a little more complicated than that, but still).
Maybe that’s not the model that real-life insurers should be copying.
No one is saying insurers aren’t horrible people and organizations denying care to patients in need. What I am saying is that “medically necessary” aren’t magical words. This is some cargo cult nonsense.
You literally say it in your own reply. “Sometimes medically necessary”. If you think nearly everything isn’t classified as that by a company who makes more money the more healthcare they don’t cover I don’t know what anyone can say to you to bring you back to the reality of US healthcare. They hire unemployable doctors with histories of malpractice to deny claims in bulk.
Did you read my reply? You’re really out of your depth here, buddy.
I did. It was truly unfortunate. After working in healthcare for a decade I thought i had seen all possible shit takes…I was wrong lol.
It isn’t about what’s actually medically necessary. Insurance companies will use any excuse to pull bs. It greatly matters how a court would view it. People are stupid and could buy the insurance companies arguments that it wasn’t made clear that it was medically necessary. Its also important that scheduled procedures are generally termed “elective” even if they are something like a necessary heart procedure. That terminology could be confusing to people who are not medically literate. Making it harder to make a case against them should something happen. They know this and fuck around. CPT codes only tell them what the condition is. There are some conditions that are not life threatening but still God awful to deal with having. You better believe they try to make people try treatments their doctor already knows won’t work and otherwise try to find excuses for why its not medically necessary.
It doesn’t matter that you don’t think such language should be necessary. This is the real world. Not some fantasy land in your head. Our Supreme Court is clearly incapable of reading the constitution. Why on earth would you think anybody else in this country would be able to read? Especially when they already have policies to intentionally hassle people because it saves them money. Its obvious you’ve never interacted extensively with the American Healthcare system or have only used it with Medicare. Preauths are one of the worst things I have to deal with at my job.
This reads like a summary of a chapter in a dystopian novel
It reads like sovereign citizen advice.
Ffs, is this truly where we are at? Fuck me…
Nurses usually make these calls, as I understand.
Why are we letting the insurance companies make decisions like doctors in the first place again again?
Because doctors have a financial incentive to order and perform/give expensive procedures and drugs that may not necessarily be medically necessary.
This is obviously a somewhat different situation, but I’d remind you that lots of doctors made a lot of money by unnecessarily prescribing Oxycontin that the spiraled into the opioid crisis.
It’s not unreasonable for there to be some kind of check, though to be clear, I’m not saying the current system is good. But, insurance just automatically paying for anything a doctor orders is open for abuse, and that needs to be addressed one way or another.
This is obviously a somewhat different situation, but I’d remind you that lots of doctors made a lot of money by unnecessarily prescribing Oxycontin that the spiraled into the opioid crisis.
Some doctors made a lot of money. Most believed what they were told and prescribed medication they thought would help their patients.
Well said. I have a nerve disorder which is controlled by medication, but it took a long time to get there and, for a while, he tried me on different opioids. I could easily have gotten seriously addicted (I did go through withdrawal symptoms after I stopped, but I had no problem stopping), but he was doing whatever he could to try and help me with my pain. He wasn’t trying to make money, he was trying to make me feel better. And it took about three years, but he finally did.
Marketing by opiate manufactureres cooked up a small study that said certain opiates had slow release versions that were less addictive and doctors bought in for a while.
I would step back a little though and say the reason people actually need so many opiates in america ties into larger problems that cause the US to have far more injuries than other countries:
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Over reliance on car infrastructure and commuting because improper zoning and lack of public transit
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Poor labor protections and safety in workplaces
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Gun fucking
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I’d remind you that lots of doctors made a lot of money by unnecessarily prescribing Oxycontin that the spiraled into the opioid crisis.
Wait, so where were these insurance companies then and why weren’t they acting as “checks” on these doctors? It couldn’t have just been a minor oversight by the insurance companies either, considering it did spiral into a nationwide crisis.
There is nothing stopping it from being a retroactive investigation. Doctor prescribes it and then has to send evidence to the Insurance Company who can review it. If there’s a pattern of Bad behavior with one doctor they can press charges or something like that. But until then you’re holding up treatment on the suspicion of the possibility.
Thats what Medicare does. People around the hospital are afraid to fuck anything up because they will go back and take all of their money back.
That’s a bullshit excuse (to be blunt). What you’re suggesting is that it’s the insurance companies job to police doctors who are doing harm to their patients. There is already a body that does this (or is supposed to): the medical board. If the insurance company feels that a doctor is abusing their privileges, then it needs to be taken up with the appropriate authorities. It does not mean causing further harm to the patient by denying possibly critical services.
We don’t have anyone to make better medical decisions than doctors. I certainly don’t want insurance company bureaucrats substituting their medical judgment for my doctor’s, even if my doctor sucks.
This is a good step in the right direction, but I’d like to see it applied to commercial plans as well. Prior authorization is everything they’re saying it is and worse.
It’s the difference between single-payer systems run by the government and private, for-profit commercial plans. I’m happy to see this carried out on an executive level since an actual law regulating private insurance would be a shit storm in congress. Remove the profit motive from insurers and the shift quickly moves towards real-world evidence and health outcomes rather than profit margins.
Were all fighting over the most miniscule things in the grand scheme. We should all be demanding the most effective and efficient single payer program the world has ever seen.
You’re right, we should be cutting out the bloated middleman entirely.
It’s true, but perfection is still the enemy of progress.
So I see you had diabetes last year. Was the insulin we gave you last year enough to cure it, or do still have it? Either way, we need to make sure you aren’t selling it to bodybuilders, so go see a doctor to confirm it hasn’t been cured.
You joke, but I’m literally fighting this fight right now.
Prescription: Your doctor thinks you need a medication
Prior Authorization: Your insurance doesn’t want pay for the medication and wants your doctor to affirm that he wrote a prescription
How about a similar rule that puts the provider on the hook for getting authorization for what they do?
Like I know the system is fucked, but I don’t want my doctor having me go somewhere to find out I get a $500 bill. Make them get authorization and if it fails tell me the cost before the appointment gets made.
If I have to spit in a tube again to get a $500 bill, I’ll call and threaten Natera again till they drop the bill. Bastards.
That would slow medical care down dramatically.
But why? This should be automated based on my coverage plan.
Because it’s not an automated process to get a procedure authorized.
Make it automated.
They already do for big services. Thats why its called a preauthorization. It just doesn’t work well in emergencies and they dont do it for shit like routine blood draws. Ive had them tell me I could get a CT now and hope they approve it or take my chances. There is still incentive for the provider to fight the battle because patients getting big bills often don’t pay them at all (it helps if you tell them though, they are busy and not necessarily keyed into every patients bill status).
Let’s not forget why Prior Authorization exists - shitty doctors who get kickbacks from labs or imaging facilities (or who own them) sending patients there unnecessarily in order to embezzle unecessary payments from Medicare and Medicaid (or even commercial) plans, draining risk pools for their own gain.
There are no good guys in America.
That is already illegal. Prior auth was not a necessary intervention for this problem.
So instead we have giant, mega corp insurance companie “non-profits” designing “AI” systems that auto deny 90% of all medical treatments and fight tooth and nail against the other 10%. All so they can drain money from patients and the goverment, injurying or directly killing milllions of americans every year for their own gain.
Neat fix.
Whats funny is you cite Medicare fraud. Medicare has a very short list of things they require preauths for. They are the easiest to work with. They do audits and if they spot any issues will take back all of the money. People are genuinely scared of that happening as it can be a lot at once if we did something wrong for a while.
