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.
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.
Cigna got caught doing it https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims I guarantee you that most other insurance companies are doing this as well.
Insurance companies are going to do anything they can to reduce loss ratio, but… That is literally the plot of a John Grisham novel (pre-ACA, so it was a little more complicated than that, but still).
Maybe that’s not the model that real-life insurers should be copying.
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.