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The Trouble with Prior Authorization (for Medical Care)

Today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need.

Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients (Lauren Sausser, KHN, 3-13-23) Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years. Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care. Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills.
      So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say. It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.

I Write About America’s Absurd Health Care System. Then I Got Caught Up in It. (Bram Sable-Smith, KHN, 1-25-22) The insurance industry defends "prior authorization" as protecting patient safety and saving money. It feels like a lot of paperwork to confirm something we already know: Without insulin, I will die. The time wasted by me, the pharmacists, the nurses and probably some insurance functionaries is astounding and likely both a cause and a symptom of the high cost of medical care. The problem is also much bigger than that.

What are the downsides to Medicare Advantage? (Explainer NY Times, 11-20-22) One big downside [to Medicare Advantage alternatives to Medicare] is that these insurers require "prior authorization," or approval in advance, for many procedures, drugs or facilities. Advantage participants who are denied care can appeal, and those who do so see the denials reversed 75 percent of the time, but only about 1 percent of beneficiaries or providers file appeals. Before signing up for a Medicare Advantage plan, understand that anytime you want care other than an emergency, the plan has to approve it. So "think very carefully before you switch out of traditional Medicare, which lets you see just about any doctor or go to any hospital." One topic under Which to Choose: Medicare or Medicare Advantage?

Prior authorization rules: Yet another way the health insurance system frustrates physicians and patients (Joseph Burns, Covering Health, Association of Health Care Journalists, 8-9-18) "For patients and physicians, many aspects of the health care and health insurance systems are frustrating and appear to be needlessly complex.
      One of the most frustrating processes is prior authorization, the mother-may-I approach health insurers use to ensure that procedures, medications and even certain care processes are appropriate and worthy of coverage. AHCJ members can access a tip sheet on covering this topic.

Why So Slow? Legislators Take on Insurers’ Delays in Approving Prescribed Treatments (Michelle Andrews, KHN,5-17-22) Insurers say prior authorization requirements are intended to reduce wasteful and inappropriate health care spending. But getting that approval can take as many as three weeks, and patients sometimes run out of insulin before it comes through. Doctors say that insurers have yet to follow through on commitments to improve the process.
      Prior authorizations take up on average almost two business days—14.9 hours—each week to complete. This leads to hiring staff who are dedicated solely to processing prior authorizations.

Pros and Cons of Prior Authorization for Value-Based Contracting (Kelsey Waddill, Health Payer Intelligence) Prior authorizations seem to also enforce the evidence-based care goals of value-based care. One of the major goals of value-based contracts and systems is to reduce unnecessary paperwork so that providers can dedicate more time to high-quality patient care. However, providers have found that prior authorizations often stand in the way of this aim.

       Also, recent research demonstrated that in some cases prior authorizations may be weaponized as tools for discrimination. instead of serving the patient population as designed. In the South, some qualified health plans on the Affordable Care Act have been shown to place prior authorizations on PrEP therapy for HIV patients.
       Plans in the South were 16 times more likely to place a prior authorization on the HIV therapy than plans in the Northeast where prior authorizations for these therapies were lowest. Yet prior authorizations are typically only applied when there are multiple drugs to choose from for a particular condition, and until recently there was only one medication option for HIV patients.

The Shocking Truth about Prior Authorization Process in Healthcare (GetReferralMD) Around 66% of prescriptions that get rejected at the pharmacy require prior authorization. When a PA requirement is imposed, only 29% of patients end up with the originally prescribed product—and 40% end up abandoning therapy altogether! Prior authorization is designed to control costs, but in practice it requires a lot of administrative time, phone calls, and recurring paperwork by both pharmacies and doctors. In 2009, one study estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. No authorization means no payment. PA problems can create a huge interruption for patients, who have to figure out whether the process is stalled out by the doctor, the insurance company, or the pharmacy.
Insurance companies can deny a request for prior authorization for reasons such as:
---The doctor or pharmacist didn’t complete the steps necessary
---Filling in the wrong paperwork or missing information such as service code or date of birth
---The physician’s office neglected to contact the insurance company due to a lack of time
---The pharmacy didn’t bill the insurance company properly
---Outdated information – claims can be denied due to outdated insurance information, such as sending the claim to the wrong insurance company
---The insurer failed to notify the pharmacy
---The approval expired after a limited time (normally 30 days)


A different kind of prior authorization:
 • Can health care providers invite or arrange for members of the media, including film crews, to enter treatment areas of their facilities without prior written authorization? (HHS.gov) Answer: Health care providers cannot invite or allow media personnel, including film crews, into treatment or other areas of their facilities where patients’ protected health information (PHI) will be accessible in written, electronic, oral, or other visual or audio form, or otherwise make PHI accessible to the media, without prior written authorization from each individual who is or will be in the area or whose PHI otherwise will be accessible to the media. Only in very limited circumstances, as set forth on this website page, does the HIPAA Privacy Rule permit health care providers to disclose protected health information to members of the media without a prior authorization signed by the individual.

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