a new set of rules from the Biden administration to rein in the use of prior authorization by private health insurers – a Byzantine practice that requires people to seek insurance company approval before receiving medications or undergoing a procedure.
The cost containment strategy often delays care and forces patients, or their doctors, to navigate opaque and labyrinthine calls.
The administration’s recently finalized rules require insurance companies working in federal programs to expedite the approval process and make decisions on emergency requests within 72 hours. The regulations will do that also require companies to provide a specific reason why a request was denied and to publicly report the denial statistics. The regulations will primarily come into effect in 2026.
While patients, advocates and researchers welcomed the new regulations, they also noted its limitations and argued that the rules do not go nearly far enough to address the magnitude of the problem.
“First and foremost, we are pleased that the Biden administration is doing something about this issue,” said Aija Nemer-Aanerud, health care campaign director for the People’s Action Institute, a grassroots organization that advocates for people who have been denied care by insurance companies. .
“The private insurance industry has come up with many ways to structure the processes – related to prior authorizations and claim denials – so that they can make a profit,” Nemer-Aanerud said. But without going any further, the rules will still allow insurance companies to, in Nemer-Aanerud’s words, “make money by denying people care.”
The Biden administration’s new rules will affect companies that work with Medicare, Medicaid and individual insurance exchanges – meaning the rules will affect approximately 105 million people. That still leaves out the largest pool of privately insured Americans – the 158 million who depend on insurance from their employer.
The new rules also exclude prior authorization for drugs, although the federal government has said it plans to work on a drug rule in the future.
In a statementAmerica’s Health Insurance Plans, a trade group, said it supports the new rule: “It is critical that we all work to ensure patients have access to the information they need to make informed health care decisions.” to take. CMS has taken a step in the right direction by finalizing the interoperability and prior authorization rule.”
Often, insurance companies argue Prior permission saves patients money by reducing unnecessary care. Particularly Americans see doctors less often than their counterparts in other developed democracies (though Americans still spend more per person). And patients, health care providers and advocates argue that insurance companies often use the process to delay and discourage patients from getting care even when they need it.
“Do I think that’s enough? No,” says Carly Morton, 30, of Beaver, Pennsylvania. “I think this is a big step in the right direction because yes, we need answers. Our medical problems are serious and painful.”
Morton has a Medicare Advantage plan through United Healthcare. A recent one Analysis from the Kaiser Family Foundation found that private companies working with Medicare, in plans like Morton’s, denied two million prior authorization requests in 2021, or 6% of all claims. Only 11% appealed.
Those who were appealed succeeded overwhelmingly (82%), leading researchers to question “whether a greater proportion of initial prior authorization requests should have been approved,” and pointing out that care would be lost anyway was delayed due to the requirement.
Morton was forced to mount a massive public pressure campaign at the People’s Action Institute to get her insurance to cover surgery for a rare vascular condition called neurogenic median arcuate ligament syndrome. Her condition left her with near-constant vomiting and “excruciating” pain that she likened to end-stage cancer. She felt stuck after trying to handle the appeals herself – she estimates she called her insurance company 50 times – before going public with her story.
after newsletter promotion
“It was very overwhelming,” said Morton, whose surgery was ultimately approved, but only after multiple press releases, videos and even coaching from a health care attorney.
United Healthcare did not comment on the prior authorization and said it could not legally comment on Morton’s case.
Plans like Morton’s are discussed. But people like 34-year-old Megan Shirk of Harrisburg, Pennsylvania, won’t do that. Shirk relies on private insurance that is linked to an employer, in this case Blue Cross Blue Shield. It bothers her complex regional pain syndromean unbearable condition also called the ‘suicide disease’, due to the large number of patients who end their lives.
“I feel like someone is kicking me and setting me on fire at the same time,” said Shirk, describing her symptoms.
Shirk and her doctors are trying to treat her condition with ketamine infusions, but so far prior authorization requests have been denied. On two occasions, the denial came the day before she was to travel 200 miles to Pittsburgh for treatment.
“We had the appointment scheduled and were ready to go,” Shirk said. “I was excited to start this new life where I didn’t necessarily have no pain, but I had manageable pain.” Shirk has been supervising the appeal procedure since October 2023.
Reflecting on the lengths she went to cover a procedure, Morton called the process “taxing in a way that I could never put into words.” She added: “Someone that sick should never, ever, ever have to go through that.”