Does prior authorization serve patients or insurers?
This is a situation that some of you have certainly encountered: you go to your doctor and you are told that you need a specific medication, treatment or procedure. But then you are told that said drug, treatment, or procedure requires prior approval from your insurance company. Sometimes the wait is tolerable. Other times, the approval process seems to take forever.
Pre-authorization – sometimes referred to as pre-approval or pre-certification – requires physicians or health care providers to obtain pre-approval from an insurance company to determine if the patient qualifies for payment coverage for a service. .
In some situations, the prior authorization process can be quite long, causing delays in treatment or care. According to a 2020 survey released by the American Medical Association, 94% of physicians report delays in care due to pre-authorization requirements from an insurance company.
When it comes to emergencies, doctors will always provide essential and life-saving care first, regardless of prior authorization requirements and insurance company policies and procedures. However, when it comes to non-emergency situations, things get a bit risky.
Elective health problems encompass a wide range of diagnoses, from acute lower back pain and shoulder injuries to more serious conditions like diabetes, which require immediate attention and care. In these non-emergency situations, prior authorization not only delays treatment, it can prevent it altogether. The delays caused by prior authorization increasingly frustrate patients to the point that they end up abandoning the procedure. majority of treatment plans absolutely. When these complications in the authorization process and the resulting delays occur, it often results in a significant deterioration in a patient’s condition, to the point where patients may require immediate medical attention and / or treatment. hospitalization.
Health insurance companies argue that prior authorization is needed to contain health care costs. However, refusing or delaying a patient to receive an essential prescription, test or treatment can have costly consequences, especially when such delays result in hospitalizations. Hospital admission alone can wipe out the initial cost savings.
Another expensive part of pre-authorization is the so-called step therapy, aka “fail first”. This policy forces patients to go against their doctor’s recommendations and try to fail on one or more medications before their insurer covers the cost of the treatment initially prescribed. Medicines can take weeks or even months to show their effectiveness, significantly delaying appropriate treatment. Stage therapy, which was initially intended to be profitable, is, in fact, more expensive in the long run.
Insurers’ barriers to physician-recommended therapies don’t just waste time for the patient. They also take time away from the doctors who provide care. Doctors complete around 40 prior authorizations per week on average, and the paperwork for them can take up to 16 hours. The time spent by physicians and health care providers carefully filling out forms to ensure insurance companies will approve treatment represents a substantial loss in patient care.
Recognizing the problems with prior authorization, the Medical Society of New Jersey conducted a study in conjunction with the New Jersey Department of Banking and Insurance. He analyzes these issues by examining approval and denial rates; how long do the pre-authorization processes take; and the services and drugs subject to these requirements.
Through the study, the MSNJ found that prior authorization requests for general care could take up to 15 days and urgent care up to three days. In the world of healthcare, where timing is imperative, these three to 15 days are significant interruptions in a patient’s treatment and can have life-threatening consequences. In One devastating example, a 25-year-old patient in Baltimore diagnosed with advanced skin cancer had skin scans delayed by prior authorization requests. By the time the doctor was able to recommend treatment, the patient was deceased.
Delayed intensive care
In New Jersey, the MSNJ study found that critical and life-saving care was delayed in the vast majority of cases. One example included a primary care physician in the Jersey center who described what happened when a patient walked into his office with a mild exacerbation of asthma and a history of hospitalization for the disease, to seek care. have their steroid inhaler refused. Some conditions may not be urgent at first, but can quickly develop into an emergency, further increasing costs within the health care system. While the doctor and his staff exchanged communications with the insurer for two days to obtain pre-authorization of the inhaler, the patient ended up being hospitalized for four days, a situation that could have been avoided altogether if the the inhaler had not been refused. in the first place.
Insurance companies certainly do not facilitate the pre-authorization process, as the previous example illustrates. In their study, MSNJ had great difficulty reporting the total volume of services and drugs requiring prior authorizations, as payers make it difficult to understand ever-changing policies. Likewise, insurers also keep information under lock and key with private portals. This lack of transparency can create barriers for physicians when payers deny prior authorizations for unknown reasons.
Despite the demanding and extensive pre-authorization process, MSNJ’s study found that the majority of applications were approved. This raises a few questions. Why force physicians to take steps if approval is guaranteed in over 90% of situations? More importantly, how can the healthcare industry improve this faulty and time-consuming process?
The MSNJ study concluded that there are serious reforms needed to the pre-authorization process, including increased automation and transparency. For example, the creation of an electronic pre-authorization system would significantly reduce the time and effort required to comply with the payor’s pre-authorization policies. Based on approval rates alone, insurance companies are also expected to reduce the number of services and drugs requiring prior authorization. The net effect would benefit not only patients, who would receive prescriptions and services on time, but also providers, who could provide more patient care after regaining previously wasted time spent working on past authorization requests. .
Lawmakers should focus on eliminating prior authorization requirements or, at the very least, ensuring that the process is standardized, transparent and immediate. Reform, streamlining and in some cases eliminating prior authorization mandates will benefit both patient and physician. The procrastination of reforming prior authorization processes only hinders competent physicians from providing essential health care services and delays patients from receiving care when they need it.