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New Biden rule cracks down on insurers’ use of prior authorization (thehill.com)

submitted 8 months ago by [email protected] to c/[email protected]

51 comments fedilink hide all child comments

A new Biden administration rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments.

Prior authorization is a common tool used by insurers but much maligned by doctors and patients, who say it’s often used to deny doctor-recommended care.

Under the final rule from the Centers for Medicare and Medicaid Services, health insurers participating in Medicare Advantage, Medicaid or the ObamaCare exchanges will need to respond to expedited prior authorization requests within 72 hours, and standard requests within seven calendar days.

The rule requires all impacted payers to include a specific reason for denying a prior authorization request. They will also be required to publicly report prior authorization metrics.

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[–] [email protected] 116 points 8 months ago (2 children)

the madness that is US “healthcare” never ceases to amaze me.

Know what happens when a doctor recommends me a treatment? I get that treatment.

I don’t have to hope an insurance company will “approve” of me getting that treatment. I don’t have to worry about paying for it.

Anyone still defending this system needs psychological help. Which would be denied by the insurance company. And cost 10000s out of pocket

[–] [email protected] 51 points 8 months ago (1 children)

It gets better. So many times Dr's will have to start with treatments they know won't work because otherwise insurance will just decline it all together.

[–] [email protected] 32 points 8 months ago (1 children)

The funny part is that this the ends up costing the insurance companies more. Nose removed, face spited.

[–] [email protected] 7 points 8 months ago* (last edited 8 months ago) (1 children)

It may cost more for that individual, which is likely additive. What's multiplicative is the number of people who don't or can't jump through the hoops and just move on. Having a tough time getting out of a subscription service? Insurance basically did it first.

[–] [email protected] 4 points 8 months ago

Agreed, they play the numbers game but at the cost of human suffering. All the cases where it costs them more though is just illustrative of the stupidity of it and helps show that there is room for legislation to curb this.

[–] [email protected] 16 points 8 months ago* (last edited 8 months ago)

Anyone still defending this system needs psychological help. Which would be denied by the insurance company. And cost 10000s out of pocket

Approximately half the country supports it because it hurts people they don't like, and they're about to elect a literal dictator. Please send help

[–] [email protected] 95 points 8 months ago (4 children)

LPT: If your doctor firmly believes that you require X treatment/medication/etc. Have them use the specific term "medically necessary". If your insurer kicks it back with that phrasing attached, contact them. Ask for the medical license number of the doctor who indicated that it was not medically necessary. Push for this information (they won't have it) and continue the line of "Someone on your end is making a medical decision against my doctors orders. I require their credentials so I can confirm they are a) qualified to make medical decisions, and b) have a higher education that my doctor possesses."

[–] [email protected] 21 points 8 months ago (2 children)

I'll be interested if someone actually tried this

[–] [email protected] 67 points 8 months ago

I speak from experience. Blue Cross has not argued or denied any of our doctors' requests since the second time I used that method.
Had a specialist tell my wife she needed a shoulder replacement. Insurance wanted her to do physical therapy. I was livid. "I want the license number of the doctor on your end who is deciding that physical therapy is going to some how magically fix torn rotator cuff tendons. Telling our medical specialist that physical therapy is required is a medical decision that contradicts their diagnosis that it needs replaced. If we follow your recommendation and it fails, I need the name and license number of who to go after for making that decision. Shielding this professional, and I use that term loosely, indicates that you're willing to assume all the liability when "physical therapy" causes more pain and damage."

[+] [email protected] -6 points 8 months ago (1 children)

It's nonsense. For one, what is required for a treatment is handled by CMS and the CPT code itself, so the necessary documentation is either there or it isn't and adding "medically necessary" doesn't change a damn thing. Secondly, the commercial payors go by their own schedules for what is always, is never, and can be "medically necessary," "experimental," "diagnostic-only," and a ton more. If your orthopedic surgeon is calling for a prior auth for a total knee replacement, it's always medically necessary; peripheral vein ablation, it's sometimes medically necessary; chin implant, never necessary.

[–] [email protected] 16 points 8 months ago (2 children)

Then I'm full of shit and my wife's reverse shoulder joint is a figment of our collective imaginations.

[–] [email protected] 2 points 8 months ago

"medically necessary" I think is just one of the descriptive words surrounding the language of the laws and forms. Its actually one of a number of phrases that should work as I'm pretty sure I've had a couple without it. Realistically any challenge that requires the insurance company to actually get a doctor to review a case should get a successful prior auth.

[+] [email protected] -10 points 8 months ago (3 children)

It's not one or the other. You're full of shit and your wife would have gotten her reverse total joint surgery regardless.

[–] [email protected] 5 points 8 months ago (1 children)

Insurers are known to automatically deny procedures based on what is essentially a flow chart (illegal) rather than a medical professional review of the case (required by law). This is why most insurers back down when a prior authorization is requested.

The whole process is being abused by insurers and if you ask doctors, nurses, pharmacists they'll tell you the process is being abused.

[–] [email protected] -2 points 8 months ago

No one is saying insurers aren't horrible people and organizations denying care to patients in need. What I am saying is that "medically necessary" aren't magical words. This is some cargo cult nonsense.

[–] [email protected] 4 points 8 months ago (1 children)

You literally say it in your own reply. "Sometimes medically necessary". If you think nearly everything isn't classified as that by a company who makes more money the more healthcare they don't cover I don't know what anyone can say to you to bring you back to the reality of US healthcare. They hire unemployable doctors with histories of malpractice to deny claims in bulk.

[–] [email protected] 0 points 8 months ago* (last edited 8 months ago)

It isn't about what's actually medically necessary. Insurance companies will use any excuse to pull bs. It greatly matters how a court would view it. People are stupid and could buy the insurance companies arguments that it wasn't made clear that it was medically necessary. Its also important that scheduled procedures are generally termed "elective" even if they are something like a necessary heart procedure. That terminology could be confusing to people who are not medically literate. Making it harder to make a case against them should something happen. They know this and fuck around. CPT codes only tell them what the condition is. There are some conditions that are not life threatening but still God awful to deal with having. You better believe they try to make people try treatments their doctor already knows won't work and otherwise try to find excuses for why its not medically necessary.

It doesn't matter that you don't think such language should be necessary. This is the real world. Not some fantasy land in your head. Our Supreme Court is clearly incapable of reading the constitution. Why on earth would you think anybody else in this country would be able to read? Especially when they already have policies to intentionally hassle people because it saves them money. Its obvious you've never interacted extensively with the American Healthcare system or have only used it with Medicare. Preauths are one of the worst things I have to deal with at my job.

[–] [email protected] 16 points 8 months ago (1 children)

This reads like a summary of a chapter in a dystopian novel

[–] [email protected] 5 points 8 months ago

It reads like sovereign citizen advice.

[–] [email protected] 7 points 8 months ago

Ffs, is this truly where we are at? Fuck me...

[–] [email protected] 1 points 8 months ago

Nurses usually make these calls, as I understand.

[–] [email protected] 56 points 8 months ago (9 children)

Why are we letting the insurance companies make decisions like doctors in the first place again again?

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[–] [email protected] 26 points 8 months ago (2 children)

This is a good step in the right direction, but I'd like to see it applied to commercial plans as well. Prior authorization is everything they're saying it is and worse.

[–] [email protected] 12 points 8 months ago

It’s the difference between single-payer systems run by the government and private, for-profit commercial plans. I’m happy to see this carried out on an executive level since an actual law regulating private insurance would be a shit storm in congress. Remove the profit motive from insurers and the shift quickly moves towards real-world evidence and health outcomes rather than profit margins.

[–] [email protected] 5 points 8 months ago (2 children)

Were all fighting over the most miniscule things in the grand scheme. We should all be demanding the most effective and efficient single payer program the world has ever seen.

[–] [email protected] 7 points 8 months ago

You're right, we should be cutting out the bloated middleman entirely.

[–] [email protected] 1 points 8 months ago

It's true, but perfection is still the enemy of progress.

[–] [email protected] 24 points 8 months ago (1 children)

So I see you had diabetes last year. Was the insulin we gave you last year enough to cure it, or do still have it? Either way, we need to make sure you aren't selling it to bodybuilders, so go see a doctor to confirm it hasn't been cured.

[–] [email protected] 13 points 8 months ago

You joke, but I'm literally fighting this fight right now.

[–] [email protected] 10 points 8 months ago* (last edited 8 months ago)

Prescription: Your doctor thinks you need a medication

Prior Authorization: Your insurance doesn't want pay for the medication and wants your doctor to affirm that he wrote a prescription

[–] [email protected] 2 points 8 months ago (2 children)

How about a similar rule that puts the provider on the hook for getting authorization for what they do?

Like I know the system is fucked, but I don't want my doctor having me go somewhere to find out I get a $500 bill. Make them get authorization and if it fails tell me the cost before the appointment gets made.

If I have to spit in a tube again to get a $500 bill, I'll call and threaten Natera again till they drop the bill. Bastards.

[–] [email protected] 1 points 8 months ago (1 children)

That would slow medical care down dramatically.

[–] [email protected] 1 points 8 months ago (1 children)

But why? This should be automated based on my coverage plan.

[–] [email protected] 1 points 8 months ago (1 children)

Because it's not an automated process to get a procedure authorized.

[–] [email protected] 1 points 8 months ago

Make it automated.

[–] [email protected] 1 points 8 months ago

They already do for big services. Thats why its called a preauthorization. It just doesn't work well in emergencies and they dont do it for shit like routine blood draws. Ive had them tell me I could get a CT now and hope they approve it or take my chances. There is still incentive for the provider to fight the battle because patients getting big bills often don't pay them at all (it helps if you tell them though, they are busy and not necessarily keyed into every patients bill status).

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