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.
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.”
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.
Then I’m full of shit and my wife’s reverse shoulder joint is a figment of our collective imaginations.
“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.
It’s not one or the other. You’re full of shit and your wife would have gotten her reverse total joint surgery regardless.
