Lawmakers are pushing prior authorization reforms as frustrations over health insurance grow

In the wake of the murder of UnitedHealthcare CEO Brian Thompson and the outpouring of frustration over insurance coverage, prior authorizations have become a particular roadblock in healthcare.

Prior authorization requires medical providers to obtain approval from an insurer before patients receive health care or medications.

“As a physician, prior authorization is the most frustrating thing about practicing outpatient medicine right now,” said Dr. Gabriel Bosslet, a pulmonologist and professor at Indiana University School of Medicine.

“I spend more time figuring out how to get this drug approved than I do seeing the patient, making a diagnosis and writing the prescription.”

Originally intended to control the costs of certain medications and treatments, the frequency of prior authorization requirements has increased in recent years and are now a blight on mainstream, low-cost care.

“This didn’t really happen five or seven years ago,” Bosslet said.

Miranda Yaver, assistant professor of health care policy and management at the University of Pittsburgh, noted that “prior authorization is something that has really proliferated with the growth of managed care in the United States.”

A study found that reforms, such as setting maximum times for insurers to respond and standardizing requests, could get patients the care they need.

Several states and the District of Columbia have passed laws to reform prior authorization practices.

So was a federal bill that would expedite such authorizations for Medicare Advantage plans reintroduced this year in Congress. The Centers for Medicare and Medicaid Services will be released in January completed a new rule to streamline prior authorizations as a way to cut costs.

Nearly a quarter (24%) of physicians say prior authorization “has resulted in a serious adverse event for a patient in their care,” according to a survey. questionnaire of the American Medical Association (AMA).

Yaver interviewed a patient with severe immunodeficiency who was denied medication because her multiple infections were serious but not yet life-threatening — “a mind-boggling assessment,” Yaver said.

The new Trump administration has signaled increased support for programs like Medicare Advantage 99% of those registered must have prior permission. That could mean more administrative burdens, more denials and hindered access to care, Yaver said.

Medical practices report an average of 43 prior authorization requests per physician each week, according to the AMA survey. That’s why more than a third (35%) employ staff whose sole role is to manage prior authorizations.

However, some requests still reach doctors.

Bosslet usually works with patients in the hospital, but once a week he sees them in a clinic. He estimates that he has to appeal denials of prior authorization by insurers every other clinic day, even after staff have filed all the necessary paperwork.

Recently, that meant a battle with an insurer to prescribe a common asthma treatment to a patient who had been relying on the medication for more than a year.

He called the number listed on the paperwork and eventually reached a person on the other end of the line who instructed Bosslet to download a form posted on the insurer’s website.

Days after submitting, he was notified that he had not completed the form quickly enough. To appeal a second time, he had to call a new number, which eventually referred him to a fax number to which he could send the new appeal – but without giving him any information about which form to use or what information about it the recipe was needed.

Part of the confusion is that “prior authorization” means something different for each insurer and plan, with different forms, questions and filing procedures.

“It’s like having to learn a completely new language every time your appeal is denied,” Bosslet said.

And all of this work must happen in addition to the time healthcare providers spend with patients.

“I try to address that in my clinic when I have patients scheduled,” Bosslet said, adding that the entire process seems designed to get providers to give up.

“The system functions exactly as it was designed to confuse and put people in positions where they have to spend more money,” he said.

Bosslet continued: “People are frustrated that health insurers are making billions of dollars.

“There is a lot of frustration that these institutions are taking enormous amounts of money out of the health care system and doing so at the expense of sick people.”

The insurer Wellcare did not respond to press questions. When first contacted, an automated message from Wellcare stated that a response would be expected within 24 hours; When contacted three days later, the message instructed journalists to email another media account.

Bosslet sent the insurer a new form with the requested information – information that was on the original prescription. That still didn’t work.

“I’m furious,” Bosslet said.

The first issue with the asthma prescription arose on December 4. At the time of writing, the drug had still not been approved. It costs $31.