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.
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
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.
The funny part is that this the ends up costing the insurance companies more. Nose removed, face spited.
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.
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
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.”
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.
Why are we letting the insurance companies make decisions like doctors in the first place again again?
Because doctors have a financial incentive to order and perform/give expensive procedures and drugs that may not necessarily be medically necessary.
This is obviously a somewhat different situation, but I’d remind you that lots of doctors made a lot of money by unnecessarily prescribing Oxycontin that the spiraled into the opioid crisis.
It’s not unreasonable for there to be some kind of check, though to be clear, I’m not saying the current system is good. But, insurance just automatically paying for anything a doctor orders is open for abuse, and that needs to be addressed one way or another.
This is obviously a somewhat different situation, but I’d remind you that lots of doctors made a lot of money by unnecessarily prescribing Oxycontin that the spiraled into the opioid crisis.
Some doctors made a lot of money. Most believed what they were told and prescribed medication they thought would help their patients.
Well said. I have a nerve disorder which is controlled by medication, but it took a long time to get there and, for a while, he tried me on different opioids. I could easily have gotten seriously addicted (I did go through withdrawal symptoms after I stopped, but I had no problem stopping), but he was doing whatever he could to try and help me with my pain. He wasn’t trying to make money, he was trying to make me feel better. And it took about three years, but he finally did.
Marketing by opiate manufactureres cooked up a small study that said certain opiates had slow release versions that were less addictive and doctors bought in for a while.
I would step back a little though and say the reason people actually need so many opiates in america ties into larger problems that cause the US to have far more injuries than other countries:
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Over reliance on car infrastructure and commuting because improper zoning and lack of public transit
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Poor labor protections and safety in workplaces
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Gun fucking
I’d remind you that lots of doctors made a lot of money by unnecessarily prescribing Oxycontin that the spiraled into the opioid crisis.
Wait, so where were these insurance companies then and why weren’t they acting as “checks” on these doctors? It couldn’t have just been a minor oversight by the insurance companies either, considering it did spiral into a nationwide crisis.
There is nothing stopping it from being a retroactive investigation. Doctor prescribes it and then has to send evidence to the Insurance Company who can review it. If there’s a pattern of Bad behavior with one doctor they can press charges or something like that. But until then you’re holding up treatment on the suspicion of the possibility.
That’s a bullshit excuse (to be blunt). What you’re suggesting is that it’s the insurance companies job to police doctors who are doing harm to their patients. There is already a body that does this (or is supposed to): the medical board. If the insurance company feels that a doctor is abusing their privileges, then it needs to be taken up with the appropriate authorities. It does not mean causing further harm to the patient by denying possibly critical services.
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.
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.
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.
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.
