By: David Ostrowsky
The message has been well received by the giants of the health insurance industry: it’s time to ease up on prior authorizations.
Whether it’s due to mounting criticism from patients and physicians, political pressure, or last December’s cold-blooded murder of UnitedHealthcare executive Brian Thompson, America’s most prominent insurance carriers—Aetna, Cigna, Kaiser Permanente, UnitedHealthcare among others—have pledged to make a concerted effort to retreat from measures that have long delayed and/or denied medical services, some of which may be life-saving.
According to the Department of Health and Human Services and AHIP, the Washington, D.C.-based national trade association representing the health insurance industry, there are six cornerstone elements of this grand plan to ensure that by the end of 2025, the prior authorization process will be significantly streamlined for both patients and providers:
Though there will be some variation among different states and employers, the adjustments will pertain to both private employer-based and government plans (i.e., Medicare and Medicaid).
While all measures promise to have a profound impact on American patients waiting for a medical procedure or prescription to be greenlighted, the last point—that actual humans with real brains, not robots fueled by artificial intelligence, will be responsible for assessing clinical denials—addresses a very sensitive topic. There have been allegations that many insurers have leveraged A/I to expedite the claim administration process and in doing so have allowed algorithms to be the final arbiter in denying patients care. Of course, such an outcome—not having to foot the bill for high-priced surgeries and procedures—goes a long way towards protecting the bottom line for insurance companies and keeping their shareholders happy. With this new plan, at the very least, even if claims are denied, a human will be able to justify the decision.
As with virtually every process in life, lower-income Americans have been the ones most burdened by the abuses of unregulated prior authorization. Whereas wealthier patients have had the wherewithal to appeal a claim, maybe even hire an advocate or attorney, most Americans simply don’t have the time and financial resources to do so. There have also been many heartbreaking stories chronicling the plight of immigrants who often struggle mightily to comprehend arcane form letters issued by insurers (correspondence that even native-born English speakers often find to be incoherent). Subsequently, many abandon plans to pursue medical care—when one is trying to cobble together an income with multiple low-paying jobs, there’s only so many hours in the day—and/or don’t realize that there is the option to appeal the decision rendered to them. Alas, these changes won’t go into effect for six months, meaning many working-class and middle-class Americans will remain so encumbered for the balance of the year. It also bears mentioning that the aforementioned list of pledges is but a voluntary commitment on behalf of the insurance carriers, though federal officials have made it clear that they will issue new regulations if insurers don’t follow through with their promises.
“We recognize the frustration people often feel about their experience,” remarked Mike Tuffin, the chief executive of AHIP, while adding that by easing the preauthorization policies, “we expect patients will feel less friction and more peace of mind.”
Meanwhile, some healthcare practitioners don’t view the matter as being so one-sided. Though patients on private insurance plans, as well as government plans such as Medicare and Medicaid, have long viewed prior authorization as a nefarious practice causing unnecessary stress leading up to surgery, carriers have countered that prior authorization has actually been critical—perhaps even necessary—for keeping healthcare costs in check as it is the only measure for avoiding excessively expensive and ultimately unneeded procedures, tests, and medications. It also bears mentioning that delays in patients receiving care may not just stem from insurers’ self-serving tactics; even with modern-day technology, many hospitals and providers continue to submit prior authorization correspondence via phone, fax, or even traditional mail.
But, of course, at this hour such beliefs are of the minority opinion. Americans have been furious with prior authorization tactics for a long time. They have spoken and the insurers appear to be listening. Now the question becomes how effective the promised changes will be.