The Feds are moving to curb prior clearance, a system that hurts and frustrates patients

When Paula Chestnut needed hip replacement surgery last year, preoperative x-rays revealed irregularities in her chest.

Having been a smoker for 40 years, Chestnut was at high risk for lung cancer. A Los Angeles specialist recommended that a 67-year-old man undergo an MRI, a high-resolution image that could help detect the disease.

But her MRI appointment kept getting cancelled, Chestnut’s son Jaron Roo told KHN. First, it was scheduled at the wrong hospital. Further, the provider was unavailable. Roux said the final hurdle she faced came when Chestnut’s insurance company deemed the MRI medically unnecessary and did not authorize the visit.

“At least four or five times she called me in hysterics,” Roux said.

A few months later, Chestnut, struggling to breathe, was taken to the emergency room. The swelling in her chest had grown so large that it pressed against her windpipe. The doctors started a course of chemotherapy, but it was too late. Despite treatment, she died in the hospital six weeks after admission.

While Ru doesn’t entirely blame the health insurance company for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things in the US healthcare system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has skyrocketed in recent years.

Prior authorization or pre-certification was developed decades ago to prevent physicians from prescribing costly tests or procedures that are not indicated or required in order to provide cost-effective care.

Originally focused on the most expensive treatments, such as cancer treatments, insurers now routinely require prior authorization for many day-to-day medical appointments, including basic imaging and prescription refills. In a 2021 survey by the American Medical Association, 40% of physicians said they have full-time employees who work exclusively by prior authorization.

So today, instead of protecting against useless and costly treatments, prior authorization prevents patients from getting the life-saving care they need, researchers and doctors say.

“The prior authorization system should be completely abolished in doctors’ offices,” said Dr. Shiha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health care plans, including Medicaid, Medicare Advantage, and the federal Affordable Care Marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Beginning in 2026, it will be required to schedule a response to a standard prior authorization request within seven days, generally instead of the current 14, and within 72 hours for urgent requests. The proposed rule was to be open for public comment by March 13.

While groups such as AHIP, the industry trade group formerly Health Plans of America, and the American Medical Association, which represents more than 250,000 doctors in the United States, have expressed support for the proposed changes, some doctors feel they haven’t gone too far. enough.

“Seven days is still too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients cannot delay treatment when they are admitted to the hospital with signs of a stroke. “We need to act very quickly. We have to make decisions.”

Meanwhile, some states have adopted their own laws to regulate this process. For example, in Oregon, health insurers must respond to non-urgent requests for prior authorization within two business days. In Michigan, insurers must report annual prior authorization data, including the number of claims denied and appeals received. Other states have passed or are considering similar laws, while in many countries insurers typically spend four to six weeks handling non-urgent appeals.

Various studies show that waiting for the approval of health insurance companies for treatment is fraught with consequences for patients. This led to delays in cancer care in Pennsylvania, meant sick children in Colorado were admitted to hospital more often, and prevented low-income patients across the country from receiving treatment for opioid addiction.

In some cases assistance was refused and never received. In other cases, prior authorization has proven to be a powerful but indirect deterrent, as few patients have the fortitude, time, or resources to navigate the confusing process of denials and appeals. They just gave up because dealing with rejection often requires patients to spend hours on the phone and computer submitting multiple forms.

Erin Konlisk, a social science researcher at the University of California, Riverside, estimated that she spent dozens of hours last summer trying to get pre-approval for a 6-mile round trip ambulance to get her mother to a clinic in San Diego.

Her 81-year-old mother has rheumatoid arthritis and had difficulty sitting, walking or standing unaided after injuring a tendon in her pelvis last year.

Conlisk thought her mom’s case was clear, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance did not arrive on the day Konlisk was told that it would. No one notified them that the trip was not pre-authorized.

According to Dr. Kathleen McManus, a medical scientist at the University of Virginia, the time it takes to process a pre-approval request can also perpetuate racial disparity and disproportionately impact those working at lower pay and hourly rates.

“When people ask for an example of structural racism in medicine, I give it to them,” McManus said. “It’s built into the system.”

A study published by McManus and colleagues in 2020 found that marketable Affordable Care Act insurance plans are 16 times more likely to require pre-approval for HIV prevention drugs in the South than in the Northeast. The reason for these regional differences is unknown. But she said that because more than half of the country’s black population lives in the south, they are more likely to face that barrier.

According to the federal government, many of the rejected claims are waived if the patient files an appeal. New data related to Medicare Advantage plans showed that 82% of appeals resulted in all or part of the original denial of prior authorization being overturned, according to KFF.

It is not only patients who are confused and frustrated by the process. Doctors said they find the system confusing and time consuming and feel their experience is being questioned.

“I lose hours of time when I don’t really need to argue… with someone who doesn’t even really understand what I’m talking about,” said Kanter, a Birmingham hematologist. “The people who make these decisions are rarely related to your field of medicine.”

Sometimes, she says, it’s more effective to send patients to the emergency room than to negotiate with their insurance plan for prior authorization for imaging or tests. But emergency care costs both the insurer and the patient more.

“It’s a terrible system,” she said.

A KFF analysis of 2021 claims data found that 9% of all in-network denials under the Affordable Care Act plans on the federal health.gov exchange were due to a lack of prior authorization or referrals, but some companies are more likely to deny claims for these reasons than others. In Texas, for example, analysis showed that 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.

Faced with scrutiny, some insurers are rethinking their prior clearance policies. UnitedHealthcare has halved the number of pre-approvals in recent years, removing the need for patients to obtain approval for certain diagnostic procedures, such as MRIs and CT scans, company spokeswoman Heather Soules said. Health insurers have also adopted artificial intelligence technology to speed up pre-clearance decisions.

Meanwhile, most patients have no way to escape the burdensome process that has become a defining feature of American healthcare. But even those who have the time and energy to fight back may not get the results they hoped for.

When the ambulance failed to arrive in July, Konlisk and her mother’s caregiver decided to take the patient to the clinic in the nurse’s car.

“She almost fell outside the office,” said Konlisk, who needed the help of five bystanders to get her mother safely to the clinic.

When her mother needed an ambulance for another visit in September, Conlisk promised to spend only one hour a day for two weeks before the clinic visit, working to secure prior approval. Her efforts were unsuccessful. Once again, her mother’s guardian took her to the clinic himself.

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